Tuesday, December 22, 2015

April's Birth Story (respectful natural hospital birth)

April's Adorable Baby
Because there are many egregious examples of bias in the maternity care of women of size, sometimes it can sound like no women of size receive respectful care during birth, but of course that's not true. There are some WONDERFUL care providers out there who really do give appropriate and respectful care to women of size during pregnancy and birth. Periodically it's important to share those stories too. That sounds like a wonderful and upbeat Christmas week post to me!

Here is the story of a "supersized" woman who gave birth recently in South Dakota. Many care providers would have predicted gloomy things based on her size (over 300 lbs.) and age (35). Yet she had a healthy pregnancy and baby, as well as an easy and completely natural birth in the hospital with a very caring OB and supportive nurses.

Remember, while there is a higher risk of some complications in "obese" women (especially as size increases), many high BMI women have completely normal and healthy pregnancies and births, especially when they take good care of themselves and are able to labor spontaneously with excellent support. 

The value of truly supportive care providers cannot be underestimated. So let me stop and speak to the care providers among my readers for a moment.
Providers, the most powerful intervention you can provide to women of size is to treat them with dignity and respect at all times. Some women of size have been so shamed and mistreated that they avoid care providers whenever possible. Regardless of what the scale says, all women deserve gentle and respectful care, but far too often they do not experience it. Respectful care can be a transformative experience for women of size who have had mostly negative contacts with health care before. Help heal that relationship; go out of your way to be as respectful and gentle as possible. 
Today, we women of size send a big shout-out to all the providers who DO provide respectful, excellent care to women of size. Thank you for all that you do.

We thank you for your gentle care and for your advocacy on our behalf. We know it's not always easy to do so in the weight-biased environment of many hospitals, but it is SO important that care like this be available to women of all sizes. Thank you for your efforts on our behalf.

And now as a holiday treat, here is April's birth story, an example of respectful care for a woman of size giving birth in the hospital.

I'm from South Dakota and I got my pregnancy care and gave birth at Sanford Hospital in Sioux Falls.  
On my first visit with my obstetrician, she did make a point of talking with us about the increased risks due to my weight (340-ish at the time) and my age (35). She said that I needed to be cautious about gaining too much weight and that I shouldn't be alarmed if I lost weight but also that I shouldn't TRY to lose weight. She also made a point of saying that even though the risks were increased, they were still quite low - especially since I am healthy with no major medical problems.  
I ended up losing about 20 pounds over the next couple of months and then my weight just stayed the same until my last month when I gained back about 5 pounds. Neither she nor any of the nurses that weighed me every visit ever commented on my weight except once when the nurse asked if I was deliberately trying not to gain weight. I told her now, that I ate when I was hungry and she was good with that, she didn't want me dieting.
I did have several ultrasounds over the course of the pregnancy but that was because she didn't like to sit still and the tech had trouble seeing the bits of her anatomy that they wanted to see. Everything went very well with the pregnancy. 
I went into active labor 2 days before my due date though I had been contracting for a couple days before that - just very far apart. I said I wanted a natural birth and they had a copy of a birth plan (checkboxes) that my obstetrician had given me months before. I also brought a simple birth plan I had typed up myself - one page with simple goals and requests. I also requested a nurse familiar with natural birth if possible.   
My nurse was wonderful. They assign each woman her own nurse so she was by my side the whole time. She was super supportive - kept saying how wonderful I was doing and helped keep my confidence up.  I didn't have an IV - they were okay with a heplock and only intermittent handheld monitoring so I had complete freedom of movement. Also, I had a jacuzzi and a shower.  
I labored from early morning until about 4pm I was 7cm dilated. Contractions came constantly after that and I got the urge to push. They checked me and I was 8cm so they said not to push. I couldn't really not push, though I tried and the midwife tried to help. 10 minutes of that and they checked me again and I was 9 1/2 and could push. FINALLY!  
I was half on my side hanging on to the bars on the side of the bed and the nurses (not the midwife) tried to get me to roll onto my back. I refused and said the doctor had said I could push in any position, even upside down (which she had said). So they let me be. 
The doc came in and it was my obstetrician since she just happened to be on call that day. She confirmed I didn't need to move and my daughter practically flew out she came so fast!  The doc almost didn't make it to the room in time - they were seeing hair! 
I believe because of this [being in a side position], the birth went very quickly and I didn't tear at all. All the nurses were very surprised and I feel that they will be more supportive of alternative positions in the future.The nurses were amazed that she came so easily and that I didn't tear even though it was pretty fast. My little girl was 7 lbs 6 oz and in perfect health. 
So, even though there was a lot of pain (though I don't really remember the worst of it now) I'm glad things went as they did and I hope you all can have as wonderful an experience as I did. 
Key thing is ask lots of questions to find out what your doc/nurse is okay with and don't be afraid to speak up for yourself, though keep it civil - if you are confrontational it will just hurt you in the end. You need to radiate calm, confidence, and that you are sure you know what you want. Also remember that we have the right to give birth in the position we choose. 
I found the book "Natural Hospital Birth" by Cynthia Gabriel very helpful also. I highly recommend anyone wanting natural birth in a hospital setting to read it - it is full of tips on how to stay in control even in the hospital. 
Also, I'd like to mention that I'm donating my extra milk to the Mother's Milk Bank of Iowa and I'd like to encourage anyone who has extra breast milk to donate to their local bank. It is so important for the little sick babies in the NICU to have breast milk.  

Tuesday, December 15, 2015

The Healing Effect of Health At Every Size College Courses

When I went to college I was truly shocked by the amount of eating-disordered behavior I saw there.

In time I discovered I knew several people with true bulimic issues, some with binge-eating, and some with anorexic tendencies. Many others simply had a lot of neuroses around food and major guilt about "being bad."

What shocked me most was that most of these eating-disordered behaviors were in people who were "normal" weight or just a bit "overweight" by societal standards.

I didn't usually see these behaviors in the fat women I knew, and I didn't see these behaviors in myself. Instead, I saw them in the people that others expected to have healthy eating behaviors compared to me.


That really shocked and surprised me. It made me start to rethink many of the things I had been taught in Weight Watchers and elsewhere. For years, I had believed that all fat people had eating problems (or they wouldn't be fat, right?) and that nearly all average-sized people did not have eating problems. I knew a few had anorexia and I'd heard about binge-eating and bulimia, but I expected most eating disorders to be in people with body size extremes.

Yet really, most of the people I met with eating disorders looked "normal." They were basically of average size, and because of that fact, they were able to hide their eating disorders very well indeed. No one would believe that they had an eating disorder just by looking at them, whereas many believed it of me based on my looks...but it wasn't true.

Now, I have to qualify that a little. After years of dieting, I had started to develop some eating-disordered behavior, but it was pretty mild. It certainly hadn't developed even remotely to the level of binge eating, anorexia, or bulimia. I was never an emotional eater, I didn't binge, nor did I have the kind of neurotic fixation on food that I saw in many of my peers. Once I realized how screwed up some people's behaviors around eating were, I realized that I was better off than I thought. I didn't have an actual eating disorder, and I realized that simply being fat certainly didn't guarantee one. And once I eventually left the dieting lifestyle, any leftover neurotic eating behaviors disappeared altogether.

College campuses are rife with eating-disordered behaviors. The good news is that some colleges are recognizing this, organizing support for those who need it, and offering coursework surrounding these issues. This is a huge step in the right direction.

I hope that college courses like the one below can help blunt some of this angst and help heal people's body issues. College is a powerful time to heal body image and eating disorder issues, so I hope more colleges will make courses like this available.

Wouldn't it be great to see something like this in medical schools too? I certainly have read about a lot of eating-disordered behavior (including compulsive exercise behavior) in medical students over the years. A Health At Every Size® course like this in medical school be incredibly valuable in influencing a more compassionate and healing approach towards body size and eating issues in future care providers.

Colleges and medical schools, are you listening?


J Nutr Educ Behav. 2015 Mar 10. pii: S1499-4046(15)00011-1. doi: 10.1016/j.jneb.2015.01.008. [Epub ahead of print] Health at Every Size College Course Reduces Dieting Behaviors and Improves Intuitive Eating, Body Esteem, and Anti-Fat Attitudes. Humphrey L1, Clifford D2, Morris MN1. PMID: 25769516
OBJECTIVE: To investigate the effects of a Health at Every Size general education course on intuitive eating, body esteem (BES), cognitive behavioral dieting scores, and anti-fat attitudes of college students. METHODS: Quasi-experimental design with 149 students in intervention (45), comparison (66), or control (46) groups. Analysis of variance and post hoc Tukey adjusted tests were used. RESULTS: Mean scores for total general education course on intuitive eating (P < .001), unconditional permission to eat (P < .001), reliance on hunger (P < .001), cognitive behavioral dieting scores (P < .001), BES appearance (P = .006), BES weight (P < .001), and anti-fat attitudes (P < .001) significantly improved from pre to post in the intervention group compared with control and comparison groups. CONCLUSION AND IMPLICATIONS: Students in the Health at Every Size class improved intuitive eating, body esteem, and anti-fat attitudes and reduced dieting behaviors compared with students in the control and comparison groups.

Wednesday, December 9, 2015

2015 studies on d-chiro-inositol

Here are a few recent (though small) studies on d-chiro-inositol (DCI) for Polycystic Ovarian Syndrome (PCOS). They had promising results. This is good news.

However, this little taste of research on DCI only points out the gaps that still exist and sure leaves me wanting more. So here's my Christmas wish list for PCOS research.

  • I would like to see some gold-standard randomized controlled studies with larger study groups. What's with all these little studies? It doesn't mean that much until it's been done with large study groups and replicated several times
  • I'd like to see more research from the USA and other countries; why are the Italians the only ones really pursuing this so closely?
  • I'd like to see more research done on how DCI affects metabolism, not just menstrual regularity, and whether it slows or prevents progression to Type II diabetes. It's really the metabolic implications that could have the most potential impact on people's health
  • I want to know if there is any interaction between metformin and DCI
  • I want to make sure DCI is safe in pregnancy and breastfeeding
  • I'd like to see DCI studied in post-menopausal women too; that is a vastly understudied group for DCI. Does it impact the incidence of diabetes, heart disease, or stroke?
  • I'd like to see DCI studied in close male relatives of women with PCOS. If PCOS women have a secondary messenger insulin signaling defect, wouldn't you think that our male relatives probably have it too? And that DCI might benefit them too?
  • I'd like to see this question about which protocol is best (DCI vs. myo-inositol vs. both) settled with better quality research

Okay, I'm cranky and demanding, but with a PCOS medication that shows this much promise, isn't it about time we had larger, more complete, and more qualitative trials?

Come on, PCOS research community, get on the stick. Stop putting out these tiny little fluff studies and start cranking out some meaningful inositol research that starts answering the most critical questions.


Gynecol Endocrinol. 2015 Jan;31(1):52-6. doi: 10.3109/09513590.2014.964201. Epub 2014 Sep 30. The menstrual cycle regularization following D-chiro-inositol treatment in PCOS women: a retrospective study. La Marca A1, Grisendi V, Dondi G, Sighinolfi G, Cianci A. PMID: 25268566
Polycystic ovary syndrome is characterized by irregular cycles, hyperandrogenism, polycystic ovary at ultrasound and insulin resistance. The effectiveness of D-chiro-inositol (DCI) treatment in improving insulin resistance in PCOS patients has been confirmed in several reports. The objective of this study was to retrospectively analyze the effect of DCI on menstrual cycle regularity in PCOS women. This was a retrospective study of patients with irregular cycles who were treated with DCI. Of all PCOS women admitted to our centre, 47 were treated with DCI and had complete medical charts. The percentage of women reporting regular menstrual cycles significantly increased with increasing duration of DCI treatment (24% and 51.6% at a mean of 6 and 15 months of treatment, respectively). Serum AMH levels and indexes of insulin resistance significantly decreased during the treatment. Low AMH levels, high HOMA index, and the presence of oligomenorrhea at the first visit were the independent predictors of obtaining regular menstrual cycle with DCI. In conclusion, the use of DCI is associated to clinical benefits for many women affected by PCOS including the improvement in insulin resistance and menstrual cycle regularity. Responders to the treatment may be identified on the basis of menstrual irregularity and hormonal or metabolic markers.
Minerva Ginecol. 2015 Aug;67(4):321-5. Epub 2015 Feb 11. Myo-inositol vs. D-chiro inositol in PCOS treatment. Formuso C1, Stracquadanio M, Ciotta L. PMID: 25670222
AIM: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women in fertile age. It is an endocrine and metabolic disorder characterized by oligo-anovulation, hyperandrogenism and insulin-resistance. Various therapeutic approaches have been attempted in PCOS, including diet and the use of pharmacological agents such as oral contraceptives (OCs) or anti-androgens. Recently, the introduction of inositol in the treatment plan has proved to be as reasonable as useful in countering the endocrine-metabolic disorders of this syndrome. METHODS: The aim of our study was to compare the clinical, endocrine and metabolic response after 6 months of therapy in 137 PCOS women characterized by oligomenorrhea and/or acne and/or mild hirsutism and insulin-resistance. The patients were treated with myo-inositol or with D-chiro-inositol or with placebo. RESULTS: Our study showed that both myo-inositol (MI-PG) and D-chiro inositol (DCI-PG) treatments are able to significantly improve the regularity of the menstrual cycle, the Acne Score, the endocrine and metabolic parameters and the insulin-resistence in young, overweight, PCOS patients. CONCLUSION: Definitely, we assumed that both treatments with myo-inositol and with D-chiro inositol could be proposed as a potential valid therapeutic approach for the treatment of patients with PCOS. Additionally, further examination and for a longer period of treatment are needed.
Arch Gynecol Obstet. 2015 May;291(5):1181-6. doi: 10.1007/s00404-014-3552-6. Epub 2014 Nov 22. Evaluation of ovarian function and metabolic factors in women affected by polycystic ovary syndrome after treatment with D-Chiro-Inositol. Laganà AS1, Barbaro L, Pizzo A. PMID: 25416201
PURPOSE: To evaluate the effects of D-Chiro-Inositol in women affected by polycystic ovary syndrome (PCOS). METHODS: We enrolled 48 patients, with homogeneous bio-physical characteristics, affected by PCOS and menstrual irregularities. These patients underwent treatment with 1 gr of D-Chiro-Inositol/die plus 400 mcg of Folic Acid/die orally for 6 months. We analyzed pre-treatment and post-treatment BMI, Systolic and Diastolic blood pressure, Ferriman-Gallwey score, Cremoncini score, serum LH, LH/FSH ratio, total and free testosterone, DHEA-S, Δ-4-androstenedione, SHBG, prolactin, glucose/IRI ratio, HOMA index, and resumption of regular menstrual cycles. RESULTS: We evidenced a statistically significant reduction of systolic blood pressure, Ferriman-Gallwey score, LH, LH/FSH ratio, total Testosterone, free Testosterone, ∆-4-Androstenedione, Prolactin, and HOMA Index; in the same patients, we noticed a statistically significant increase of SHBG and Glycemia/IRI ratio. Moreover, we observed statistically significant (62.5%; p < 0.05) post-treatment menstrual cycle regularization. CONCLUSIONS: D-Chiro-Inositol is effective in improving ovarian function and metabolism of patients affected by PCOS.

Tuesday, December 1, 2015

Physical Recovery After CBAC

Artwork by Molly Remer, from Brigid's Grove Etsy Shop
Recently, we have been talking about Cesarean Birth After Cesarean, or CBAC (some people prefer Cesarean Surgery After Cesarean, or CSAC). This is when someone wants and works for a VBAC but doesn't have one. Usually it means that she labored but ended up with a repeat cesarean, but sometimes it can involve an unwanted planned repeat cesarean that was done for medical indications or because of unsupportive providers. It is the unwanted aspect of it that is most important.

As we have discussed, everyone celebrates a VBAC but many CBAC mothers feel alone and unsupported, both in their physical and emotional recovery. This needs to change.

As part of our CBAC emphasis this past month, I shared my CBAC story a few weeks ago, as well as the CBAC support website I created to discuss the many feelings that a CBAC can involve and some ideas for working through them. I also wrote a 3-part series for the Science and Sensibility blog that discusses how birth professionals can better support people who have had a CBAC:
  • Part One - CBAC: A Unique Grief
  • Part Two - CBAC: The Forgotten Mothers
  • Part Three - CBAC: Supporting Women When VBAC Doesn't Happen
For the International Cesarean Awareness Network (ICAN), I wrote a brochure on CBAC so birth professionals have something to give the CBAC mother immediately afterwards to help support her emotional journey. And I will be recording several webinars for ICAN about CBAC as well.

For my last posts in this series here on this blog, I'd like to focus on physical healing after a CBAC, what you might be feeling after a CBAC, and some things you might do to help in  your emotional healing as well. As always, take what works for you and leave the rest behind.

Physical Recovery

Having a CBAC is hard. Usually it involves recovering from both the rigors of labor and major surgery, and of course recovery can be harder after multiple cesareans. In addition, CBAC mothers have a higher incidence of complications like infections and bleeding, and about 2% experience significant morbidity.

It is hard to process emotions when your body is struggling to heal. Many women find it is helpful to focus first on physical recovery after a CBAC. Here are some ideas to help promote physical recovery.
  • Rest as much as you can. The most potent tool for physical healing is rest. If you are doing too much, your body must divert energy from its recovery. It can be hard to get enough rest with a new baby, but with the support of others, you can prioritize as much rest as circumstances allow
  • Ask for help. Don't be afraid to enlist help from friends, family, your partner, or a post-partum doula. Others should be doing the cooking, cleaning, shopping, and caring for other children; your priority is to feed the baby and sleep as much as possible at first 
  • Take pain meds when needed - Don't neglect pain medication post-partum; you've had surgery. Take them a little bit early, before the pain gets ahead of you. Taper them off over time, but don't be afraid to take them for as long as you need them
  • Set up your home to make recovery easier. Have all the supplies you need right at hand, including a water bottle, the phone, extra diapers and burp cloths, healthy snacks, a footstool, and extra pillows to make positioning more comfortable. Include some entertainment for yourself (a book, the TV remote, music) for those moments when baby just won't let you get up
  • Eat healthy. Your body needs help to repair tissue and replace lost fluids. Get plenty of iron-rich and vitamin C foods and stay well-hydrated to replenish your blood supply. Adequate protein plus vitamins A and E are important in helping to rebuild tissue. Let others feed you, but keep around plenty of easy snack foods like string cheese, nuts, fresh and dried fruit, and pre-sliced vegetables to make grabbing a bite easier while caring for the baby
  • Don't go back to your regular schedule too quickly - Many women go back to a normal schedule too soon after a baby is born, and their body lets them know it's too soon with increased bleeding and pain. Respect what your body is telling you. Take it easy for as long as you can once you get home from the hospital
None of these hints is a magic pill that will wipe away all pain and difficulty. You still will have a surgical recovery, with all the pain and fatigue that entails. Although CBACs are usually harder than primary cesareans, not all are hard. Some have an easy recovery. Others have more difficult recoveries, and a few have very complicated recoveries. Let's talk more about these. 

Dealing with Complications

Although major injuries are quite unusual after CBAC, they do sometimes occur. Women who have experienced major physical trauma (like severe bleeding, significant infection, severe scar tissue, surgical injury to nearby organs, uterine rupture, or hysterectomy) will need significant support as they recover.

If you have experienced complications, it is important to take recovery slowly, since set-backs can easily occur. Get as much rest as possible and seek out complementary therapies like acupuncture, chiropractic, Maya Abdominal Massage, physical therapy, or nutritional counseling to help support your recovery.


One study found that about 35% of CBAC women experienced significant bleeding, while other studies have found much lower rates. Differing thresholds for defining hemorrhage explains many of these differences, but blood loss is a real risk to be aware of.

If you experienced significant bleeding during your labor or cesarean, have your provider check you for anemia. Being anemic can make healing more difficult, impair milk supply, and prolong fatigue, yet many providers are not proactive about monitoring for this. Taking extra iron, eating iron-rich foods, and taking supplements like Floradix can help your iron levels recover. Women with hypothyroidism may have more trouble with anemia and should probably be extra proactive about this and have additional tests.

If you experienced a major hemorrhage, you should be watched for Sheehan's Syndrome. This is when part of the pituitary gland dies due to a relative lack of blood supply to the area if a hemorrhage happens during childbirth. This can impact milk supply negatively and eventually lead to secondary thyroid dysfunction and many other distressing symptoms. Sheehan's Syndrome often doesn't present fully until years later, sometimes not fully triggered until a successive health crisis (surgery, infection) causes an adrenal crisis. If you experienced a major hemorrhage during your birth, be aware of the symptoms of Sheehan's Syndrome and be ready to advocate for testing if needed.


Women who have a cesarean after a VBAC trial of labor have increased rates of infectious morbidity. One study found that 25% of CBAC women experienced chorioamnionitis afterwards, although other studies have found lower rates.

If you experienced a major infection after your CBAC, this can involve a long hard healing process. If you are still in the hospital (or are readmitted later), ask about IV antibiotics instead of oral ones, and ask for a consult with a wound or infection specialist.

Some women have had better healing on an infected cesarean wound using a wound vacuum (Negative Pressure Wound Therapy, NPWT), while others have found it painful and not very useful. Basically it sucks out fluids and infection and draws more blood to the area to improve healing. Bandages are changed about 3x/week, which some women find quite painful; be sure to take your pain meds at least an hour ahead of time. Some people report that using alcohol between the skin and the bandage ahead of time can help remove adhesive tape more easily, and infusing saline first into the sponge inside the wound can ease its removal considerably.

Medical-grade honey is another option (FDA-approved) that has shown some promise in limited studies. It is rarely utilized for cesarean wound issues in first-world countries, but can be another option to consider if you do not want the wound vacuum or find it too painful. You might have to strongly advocate for it since it is used more often in non-obstetric wounds and most OBs won't be familiar with it.

If you are heavy, ask about using weight-based dosing for your antibiotics. Not all antibiotics need weight-based dosing but many do, yet the research shows that the majority of doctors tend to under-dose patients of size, especially those with a very high BMI. Research also shows that "obese" people benefit significantly from longer courses of antibiotics, IV antibiotics instead of just oral ones, and more frequent dosing regimens, so ask your care provider to consider these options too.

Scar Tissue and Nerve Damage

Some women develop significant internal scar tissue (adhesions); the more cesareans you have, the more at risk for adhesions you are. One study found that 46% of women with three or more cesareans had developed "dense" adhesions. These types of adhesions can lead to significant pelvic pain, difficult menstruation, and even bowel obstructions.

Severe cases of adhesions may require additional surgery to break them up. Although this has the risk of creating more adhesions, some women find significant relief with it. Other women are able to address pelvic pain from adhesions through physical therapy, massage, yoga, acupuncture, and Maya Abdominal Massage techniques, which can help loosen and break up the scar tissue.

Some women experience long-term numbness after their cesarean from nerve damage. Although this has little medical significance, it can have significant emotional significance to the woman involved, who may mourn loss of sensation in the area. Sometimes an "itching" feeling can be felt from the inside, even though scratching on the outside does not help. The loss of sensation in the area around the scar is often cited by cesarean mothers as one of the more distressing results of their cesareans. Again, the techniques above may help loosen scar tissue and restore some degree of nerve function.

Injuries to Nearby Organs

Because the uterus is located in the abdomen, one of the risks of surgical birth is injury to nearby organs like the bladder and bowels. This is not a big risk, but if it happens to you it is a big deal.

One study found an incidence of 0.86% of bladder injuries in women who had a CBAC after a trial of labor. Although this risk is low, it does increase in the face of prior cesareans, especially if dense adhesions are present. It is also increased in the face of induction and augmentation.

Sometimes these injuries occur for other reasons. One CSAC mother I know shares her story of recovery after a severe surgical injury by a doctor who was angry with her for laboring "so long":
My bladder was severely damaged through a surgical error during my CSAC. The surgical error was made in an O.R. environment of carelessness and anger that I had fought against CSAC and labored for so long (~60 hours).
Things that helped me recover were: Time, innate stubbornness, acupuncture to help my bladder relearn how to contract after surgical reconstruction, EMDR therapy for PTSD, and antidepressants. My recovery was long and so hard and 7 years later I can finally see the progress I've made.
Uterine Rupture

Uterine rupture is rare but it does happen occasionally. When it happens, it can be absolutely devastating, emotionally and physically. Although usually the rupture is able to be dealt with in a way that preserves both the uterus and the baby, in worst case scenarios the uterus, the baby, or both may be lost. The mother can be left with tremendous physical and emotional trauma.

Obviously, the mother will need to watch for many of the complications listed above. Sheehan's syndrome in particular should be monitored for. Once the initial healing is over, the mother may feel better physically with some of the complementary therapies listed above.

There are groups that specialize in support for women who have had a uterine rupture. You can find more information about these groups here and here. Please also look into the resource groups listed below that help women deal with birth trauma.


Women who have a CBAC are at increased risk for hysterectomy, although the absolute risk for this is also low. In one study, about 1% of CBAC women had a hysterectomy during labor.

Of course, if you are among that 1%, it feels like a very personal risk. To lose your uterus and all future childbearing potential is a tremendous grief. Even though the hysterectomy may have been necessary, it still can be traumatic to recover from physically. Hormonal changes due to the hysterectomy may intensify both the physical and emotional recovery. Find a sympathetic care provider to help ease you through these changes. A naturopath or a doctor with a more "alternative" mindset may be your best bet. Acupuncture may also help ease these changes.

Unfortunately, there are not a lot of resources available specifically for women who experience hysterectomy after a trial of labor. There are groups that offer support after hysterectomies in general; these groups can be found here and here. If you search on these sites for "hysterectomy during childbirth" you will find other women who have had similar experiences. Here is a link to an article on coping with unexpected hysterectomies.

Women who lose their uterus during childbirth may develop symptoms of Post-Traumatic Stress Disorder (PTSD). There are a number of organizations out there who can help women dealing with PTSD after childbirth, including Solace for Mothers and others listed below.


The good news is that research shows that the rate of significant complications after a CBAC is quite low. Medically speaking, most CBAC mothers will experience a pretty unremarkable recovery.

However, recovering from a cesarean is always a challenge, especially when you already have older children to take care of. Many mothers try to do too much too soon and end up delaying their recovery and exhausting themselves. It's important to remember that you've had major surgery and to let others take care of you as much as possible.

If you experienced a complication after a CBAC, that can make your recovery, both physical and emotional, harder. Even more difficult are the rare but very serious complications like injuries to adjacent organs, uterine rupture, or hysterectomy. If this has happened to you, please be sure to get extra support for your physical healing and personal support for your emotional healing.

Although most women benefit from focusing first on their immediate physical recovery, sometimes the emotions of a CBAC are so overwhelming that they need to be addressed right away in conjunction with the physical healing.

If you feel overwhelmed emotionally, find a way to debrief the birth as soon as you can. This can be with your providers (if they are supportive), with a doula, with a birth-friendly therapist, or with your partner. The important thing is to find someone who is truly supportive and emotionally safe to speak to, not someone who will downplay your emotions or tell you to "just get over it."

Finding a support group of like-minded women who have been through a similar experience is also vital in dealing with birth trauma. See the resources below for links to birth trauma resources and support groups.

More on emotional recovery in the next post in the CBAC series.


Emotional Support for CBAC Mothers:
Emotional Support After a Difficult Birth:

*Note: The medical community uses the term "failed" in the following abstracts. Do not let their terminology bring you down. We are NOT failures and we did not fail. 

Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA. Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section. Am J Perinatol 2011 Mar;28(3):181-6. PMID: 20842616
...We set out to identify factors that are predictive of major morbidity in women who attempt VBAC. A nested case-control study was performed within a large retrospective cohort study of women with a history of at least one cesarean. Women who attempted VBAC were identified and those who experienced at least one complication of a composite adverse outcome consisting of uterine rupture, bladder injury, and bowel injury (cases) were compared with those who did not experience one of these adverse outcomes (controls)...Of 25,005 women with a history of previous cesarean, 13,706 (54.9%) attempted VBAC. The composite outcome occurred in 300 (2.1%) women attempting VBAC. Using logistic regression analysis, prior abdominal surgery (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.2 to 2.1), augmented labor (OR 1.78, 95% CI 1.29 to 2.46), and induction of labor (OR 2.03, 95% CI 1.48 to 2.76) were associated with an increased risk of the composite outcome. Prior vaginal delivery (OR 0.39, 95% CI 0.29 to 0.54) was associated with decreased risk for the composite outcome...Women attempting VBAC with a history of abdominal surgery or those who undergo augmentation or induction of labor are at an increased risk for major maternal morbidity, and women with a prior vaginal delivery have a decreased risk of major morbidity. The multivariable model developed cannot accurately predict major maternal morbidity.
Obstet Gynecol. 2006 Jul;108(1):21-6. Maternal complications associated with multiple cesarean deliveries. Nisenblat V1, Barak S, Griness OB, Degani S, Ohel G, Gonen R. PMID: 16816051
...The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group). RESULTS: Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004). CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number.
Am J Obstet Gynecol. 2007 Jun;196(6):583.e1-5; discussion 583.e5. Perinatal outcomes after successful and failed trials of labor after cesarean delivery. El-Sayed YY1, Watkins MM, Fix M, Druzin ML, Pullen KM, Caughey AB. PMID: 17547905
...Matched maternal and neonatal data from 1993-1999 in women with singleton term pregnancies with prior cesarean undergoing trial of labor were reviewed. Women with uterine rupture were excluded. Maternal and neonatal outcomes were analyzed for successful and failed trials. Predictors of success and failure were examined. RESULTS: 1284 women and their neonates were available for analysis. 1094 (85.2%) had a vaginal birth and 190 (14.8%) underwent repeat cesarean. Failed trials of labor were associated with higher incidence of choriamnionitis (25.8% vs. 5.5%, P<.001), postpartum hemorrhage (35.8% vs. 15.8%, P<.001), hysterectomy (1% vs. 0%, P=.022), neonatal jaundice (17.4% vs.10.2%, P=.004) and composite major neonatal morbidities (6.3% vs. 2.8%, P=.014). CONCLUSION: Failed trial of labor in women at term with prior cesarean is associated with increased maternal and neonatal morbidities.

Friday, November 13, 2015

My CBAC series on Science and Sensibility

This month, we are talking about Cesarean Birth After Cesarean, or CBAC.

CBAC is the preferred term for when a mother works for and wants a VBAC but ends up with another cesarean. Medical researchers usually call this a "failed" VBAC or a "failed trial of labor after cesarean" but this terminology is insensitive. Women who did not get a VBAC are not failures. The reality of birth is much grayer than a black-or-white, success-or-failure binary equation.

I had a CBAC with my second child, as I wrote about on this blog last week. Although I did go on to have two VBACs afterwards, the CBAC experience left a strong imprint on my soul, and pointed out to me the need to improve our emotional support for women who experience one.

In honor of this topic, I wrote a 3-part series on Supporting Women When VBAC Doesn't Happen, and it was published over on the childbirth blog, Science and Sensibility. The different posts include:
  • Part One: A Unique Grief - discusses how a CBAC is not the same as a primary cesarean or a planned repeat cesarean that was gladly chosen, as well as the vacuum of support that many CBAC mothers experience from care providers, friends and family, and the birth community 
  • Part Two: The Forgotten Mothers - discusses how CBAC mothers are largely ignored in medical research, reviews what little research there is on CBAC, and discusses what we can learn from it and from CBAC mothers' experiences
  • Part Three: Supporting CBAC Mothers - discusses concrete suggestions on how birth professionals and friends/family can support CBAC mothers

There is also a new brochure on CBAC that I helped write for the International Cesarean Awareness Network. This gives birth professionals something concrete to give to new CBAC mothers. (There are other ideas for supporting CBAC mothers available in Part 3 of the Science and Sensibility series linked above.)

In addition, I helped write a new CBAC support website, using materials brainstormed by CBAC moms for a workshop I did at an ICAN conference.

I am also offering two webinars on CBAC for ICAN this month (they will be listed with ICAN once they have been recorded; members can access them afterwards). One is for folks in the birth field to learn how to support CBAC women more effectively, and the other is for CBAC mothers themselves.

When I had my CBAC so many years ago, there was a real dearth of information on supporting CBAC mothers. No one knew how to help, and I got precious little support. Eventually we built a community of CBAC moms who helped each other. Together we brainstormed what kind of support was and was not helpful. We built the support network that we needed. It didn't take the pain and disappointment away of course, but it helped ease the process of coming to terms with it.

Far too often, there is still a dearth of support for CBAC mothers because few people know what support resources exist. My hope is that this Science and Sensibility series, the new brochure, the new website, and the webinars can help fill in gap, along with ICAN's Facebook support page.

But this shouldn't be the end of it. We need to continue to dialogue on what's needed to improve support for CBAC moms. However, that dialogue won't happen if other folks in the birth community are not aware of these concerns or have no concrete ideas on how to help.

So please, go check out the series and "like" or "share" it on Facebook and other social media. Make sure that people in the birth field, whether care providers, doulas, advocates, or moms themselves, have access to the message about improving support for CBAC moms.

Let's make sure that women who don't get a VBAC know that they are not alone and that all the work they put in their pregnancy and towards their birth still counts. ALL women deserve support; let's raise awareness of the needs of CBAC mothers and reach out to them with kindness and empathy as they work towards emotionally processing the experience and integrating it into their lives. 

Wednesday, November 4, 2015

Cesarean Birth After Cesarean, 18 Years Later

Image from Wikimedia Commons, here
  Remember, no effort that we make to attain something beautiful is ever lost. –Helen Keller

This month, we are focusing on CBAC, or Cesarean Birth After Cesarean. The following was expanded from an article written for the Spring 2015 Clarion, a publication of the International Cesarean Awareness Network (ICAN), now appearing on the ICAN blog

My CBAC Story

Eighteen years ago, my second child was born. He was born by repeat cesarean after a long, hard “trial of labor” which included 5 hours of pushing with no progress because he was big and posterior with an upright (“military”) head position.

I’ve second-guessed that birth for many years. It’s possible that if we’d pushed even longer, his head would have molded enough to fit through my pelvis and turn anterior on the perineum, as many posterior babies do. However, at that point, I was absolutely exhausted, in a lot of pain, and was worried about the wisdom of continuing when things had gone so long without progress. I knew a non-progressing labor was a risk factor for rupture, plus my baby had experienced some issues with his heart rate. They resolved, but I didn’t want to go into a repeat cesarean in true emergency mode because of a rupture or fetal distress, and emotionally I needed to make sure that I didn’t have an anesthesia failure like I did with my first cesarean.

At that point, I just had a strong sense of Inner Knowing that it was time to be prudent and stop before things became a real emergency. I believe I made the right decision, but it was hard to communicate that to my husband and support team. My doula treated me like I had wimped out and thrown in the towel too easily. I never heard from her again after the cesarean. It was clear she viewed me as a failure.

I dreaded having to go back to my VBAC groups and tell them I’d had a CBAC, but I gritted my teeth and did it anyway. I got some sympathetic responses, but mostly I got a lot of silence or tepid responses that felt judgmental. No one knew how to reply to someone who hadn’t gotten their VBAC . 

Over the years, there was a lot of armchair quarterbacking about my decisions. People meant well, but I was left feeling pretty unsupported. And I didn’t feel I could really emotionally process the birth fully in birth spaces because I was afraid of discouraging new mothers or those planning their VBACs. No one wants to hear about when VBAC doesn’t work out.

Eventually I was able to access some resources that helped me emotionally process my first two births. It took a lot of hard, emotionally grueling work, but in time I came to peace with those births, and I did have two VBACs afterwards. 

In some ways, the CBAC was healing from my highly traumatic first cesarean, but in other ways it would always remain hard, even though I felt like it was a prudent and wise call under the circumstances. My consolation was my precious child, but his birth would always remain bittersweet to me in some ways, especially because of the initial lack of support. And that led me to trying to improve support for other women who had difficult or traumatic births, especially CBAC mothers. 

Expanding CBAC Support

If about 75% of labors after cesarean end up with a VBAC, that means that about 25% of these labors end with another cesarean. Where is the support for women who have an undesired second cesarean? Where is the acknowledgement of all the work they put in towards a VBAC, the hours of labor, the pain, the worry? Does all that preparation and work not count if you don’t end up with a VBAC? 

In time, I began to realize there was a vacuum of support for the mothers who didn’t VBAC. It wasn’t just about my own experience anymore, but also about other moms. How could we make it so that all mothers felt supported, regardless of outcome? Shouldn't we offer emotional support after any cesarean, whether it’s your first or another one?

I wasn’t the only one, of course. A number of us shared this experience of another unwanted cesarean, including people in the leadership of ICAN, and we began to talk about how to offer better support. One of the first things we did was ditch the terms used in the medical literature, terms like “Failed VBAC” or “Failed Trial of Labor After Cesarean.” We felt this was too judgmental and insensitive. We were not “failures,” we did not fail, and we should not have been on trial.

We created the term Cesarean Birth After Cesarean (CBAC) as a more mother-friendly alternative. It refers to a cesarean that occurs when the mother really wanted and worked for a VBAC but didn’t get one. These women had different emotional needs than those who wanted a repeat cesarean, and terminology needed to reflect that difference. So we used “CBAC” to differentiate another unwanted cesarean from Elective Repeat Cesarean Section (ERCS), where women truly wanted another cesarean and voluntarily chose it. Neither one is good or bad; they are simply different experiences.

There are many shades of CBAC. Most of the time, it refers to someone who labored and ended with another cesarean, but it can also refer to a cesarean performed before labor for medical reasons, because the mother had no choice, or because the mother was coerced or scared into a repeat cesarean. Some women prefer "CSAC" (Cesarean Surgery After Cesarean) because they consider the term “birth” too emotionally loaded. Women get to choose the term that seems right for their own experience. The important thing is to acknowledge and validate the range of feelings that women have over this experience.

Of course, all CBAC mothers are not alike. Having the shared experience of a CBAC doesn’t mean other details of our situations are similar. Each CBAC is unique, and each carries its own particular color and resonance of pain. 

Some had disappointing or traumatic experiences, and some didn't. Some felt very betrayed by their caregivers, while others had very supportive caregivers. Some felt they had a “prudent CBAC,” where although it was difficult, a repeat cesarean felt like the right choice under the circumstances. Some had an “empowered CBAC,” where even though there was disappointment and sadness, there was powerful learning and healing too.  

Some CBAC mothers go on to have a VBAC eventually, while others never do. Some have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, and damage to or loss of their baby. As always, each person’s experience is different and unique, and each CBAC mother needs safe space to process all the varying feelings about those experiences. But this can be difficult to do within regular birth forums.

Some people don’t think there needs to be any separate support for CBAC mothers (“a cesarean is a cesarean”), and to this day, many of us with CBACs still have our decisions questioned and second-guessed in birth forums. Although many doubters have come around to offer more support, CBAC still remains a topic of friction at times within the birth community. This needs to change. 

New CBAC Resources

Over the years, we have tried to expand resources for CBAC mothers. We have offered several CBAC sessions at ICAN conferences and at local chapter meetings, and until recently we had a Yahoo group for online support. 

In 2011, I offered a CBAC workshop at the St. Louis ICAN conference. The session was derived from discussions by mothers on the Yahoo CBAC Support Group, and many graciously consented to sharing their thoughts and quotes to help others. At that session, we brainstormed ways to offer further support for CBAC moms. 

One of the main ideas was to have an online website devoted to CBAC support and information. So last year, Melek Speros, Catherine Kowalik Harper, and I created a CBAC Support website, based on my material from the 2011 workshop and suggestions I got there. On this site, we share CBAC research, websites where CBAC moms can go for emotional healing, information on the unique emotional needs of CBAC mothers, suggestions for processing a CBAC, CBAC birth stories, inspirational quotes for healing, and suggestions for birth professionals to help them better support CBAC mothers. 

ICAN has also created a new online support group via a Facebook page for CBAC mothers. This is a closed group; you have to be a CBAC mother to join. It offers intensive, personal support for those dealing with the aftermath of a CBAC. 

ICAN is also about to publish a brand-new brochure on CBAC. It is intended for ICAN leaders and other birth professionals who may encounter a woman who has recently had a CBAC and is in need of extra support. We encourage birth professionals to include this brochure in a resource packet that they can send to women shortly after a CBAC so these mothers realize that they are not alone, that others have walked the CBAC trail and survived, and that there are resources for further support if they want it. 

In future years, I hope we can create even more ways to help support CBAC mothers. If you have other suggestions for how we can do that, please add them in the comments section. 

Final Thoughts

Eighteen years after my own CBAC, it remains a potent memory. My sweet little boy is a strong and independent man now, flying off on new adventures, but his birth is still a touchstone for many different emotions. Although I did eventually go on to have 2 VBACs after the CBAC, those experiences didn’t "fix" the CBAC or make it go away. They simply are different entities – not better or worse, just different. Although there are things I still mourn about my CBAC, I have learned to honor all my birth experiences, difficult or easy, because they are a big part of the person I am today.

The lessons I learned from my CBAC remain powerful and still resonate in my life. My CBAC helped me to be more compassionate about other people’s births, to recognize that sometimes there are just things that are beyond our control in the moment. It helped me to realize that sometimes birth is more about the willingness to heal and change; that birth is more about the journey and less about the destination. 

In time I learned to honor both the disappointment and the joy in all my births, to remember that what counts most is the parenting we do throughout life rather than how we birth, but also that how we feel about our births counts, even years later. Our deep love for our children is a different and separate thing from our emotions about their births, and while these things intertwine, one does not take away from the other. We can honor the disappointment and mourn the difficulty of a birth while still celebrating and fiercely loving the child that came from that birth. 

I found that out of my suffering came the ability to transform pain into advocacy. I found my voice in a new and potent way, and I have endeavored to channel the power of that voice to create change, as well as to create and hold safe space for other women and their unique experiences.

A CBAC is never an easy thing. The pain and disappointment of it stays with you forever, but like other grief, it does ease some and you find a way to live with it, just as you find a way to live with other disappointments in your life. You can celebrate certain aspects of it, you can mourn parts of it, you can still be upset that it occurred, but you honor what it has brought to your life, both difficult and wonderful. 

You also learn that in time, out of the pain and conflicting emotions that accompany a difficult experience, there can also come great growth and power to create change for yourself and others. Just give yourself the gift of time and space for that healing. It will come.

Monday, November 2, 2015

A Discussion of the Barriers to VBAC

Dr. Mark Landon
The majority of women who have a cesarean in one pregnancy go on to have cesareans in subsequent pregnancies. Sometimes it's because that's what they want (which is perfectly fine), but often it's because they are not given any choice in the matter. That's not fine.

Sadly, many hospitals or caregivers will not "allow" Vaginal Births After Cesarean (VBACs). Some say they allow it, but in the end the caregiver ends up scaring or pressuring the mother out of VBAC, or put so many restrictions on it that it's practically a miracle if the mother gets one.

There are risks to VBAC that are real and must be considered, but there are also real risks to repeat cesareans, especially multiple repeat cesareans. The rise in the incidence of placenta previa and placenta accreta, both life-threatening conditions, is tied to the rise in cesareans, especially repeat cesareans. Yet women are often not being adequately counseled about the risks of cesareans.

The "trial of labor" (TOL) rate for VBACs in the United States now is much lower than in Europe, and much lower than it used to be here in the U.S. The U.S. medical community, by and large, turned its back on VBAC in the early 2000s. While the rules around VBAC were loosened a bit a few years ago in order to help make it more available to women, this hasn't really happened. Many providers and hospitals still do not allow women to choose VBAC, even though about 70% of women who try for a VBAC will have one.

The following article is an excellent overall summary on the barriers to VBAC in the U.S. from one of the leading experts on VBAC, Dr. Mark Landon. If you haven't had a chance to read it yet, definitely check it out.


Friday, October 23, 2015

Metformin Does NOT Lower Birthweight Among Non-Diabetic Obese Mothers

Although most higher-BMI women have average-sized babies, larger women have a higher percentage of big babies. This is one of the biggest reasons care providers intervene in the pregnancies of women of size.

Although most big babies do just fine, bigger babies do have higher rates of issues like shoulder dystocia, cesarean birth, and low blood sugar after birth. So care providers have long searched for ways to lower the rate of big babies among women of size.

Whether that's justified or not is a debate for another day. The point is that many care providers are willing to go to extreme lengths for this goal.

A few years ago there was a large public campaign pushing the prescription of metformin (brand name: Glucophage) for reducing birthweights among non-diabetic "obese" mothers.

We've written about this before. The study was called EMPOWaR and was a randomized, controlled study at 15 different U.K. hospitals.

The theory was that insulin resistance and/or borderline blood sugars were probably at the root of a higher incidence of large infants among high-BMI women, and that lowering blood sugar and insulin resistance even in non-diabetic obese mothers might improve outcomes.

While the publicity campaign noted that they were just investigating this possibility ─ really! ─ the publicity push around a study that hadn't even been done yet suggests that the investigators really had ulterior motives.

Pushing Unproven Agendas Through Publicity 

This is one of my pet peeves about research on obesity in pregnancy; it is often publicized now before the study is even done. One suspects that the researchers are trying to promote unproven high-intervention protocols for this group, trying to raise their own public profiles, or maybe even create a new market for certain medications or programs.

Why else would researchers publicize a study not yet even done?

Publicizing a research trial before it's done creates an expectation in the reading public, including other doctors, that a particular protocol or medication is THE way to manage a particular population or problem. It does an end run around the usual research procedures and starts promoting protocol changes in the minds of the public without having to wait for any pesky results.

We've seen it before in a Kaiser study that promoted zero weight gain in obese pregnant women before the study had even been done. Best guess is that it was part of a push from some doctors to lower prenatal weight gain guidelines because they didn't think the 2009 guidelines (11-20 lbs. for obese women) were low enough.

Certainly, doctors can campaign for changes to national guidelines because of strongly-held beliefs that a particular approach might improve outcomes. However, a pet theory is not enough; any changes need to be supported by actual evidence.

It is medically unethical for doctors to be promoting changes to policy without having clear data that shows a need for such changes and conclusive proof of a lack of harm of such changes.

And guess what? There is good reason for demanding such proof of lack of harm before guideline changes. Turns out that there IS harm in minuscule weight gains.

recent meta-analysis of 18 cohort studies concluded that "gestational weight gain below the guidelines cannot be routinely recommended" in obese women because of an increase in too-small infants and premature births.

THAT is why you need to show proof of a lack of harm of proposed changes and why no one should be publicizing studies before they are done. Doctors all over the country ─ outside of the research trials ─ took that publicity push seriously and are currently promoting minuscule gains, zero gain, and even weight loss in obese pregnant women. How many premature babies and too-small babies have been the result?

Promote healthy eating and lifestyle? Absolutely. And some larger women naturally gain very little in pregnancy, even with normal eating. That's okay; those women generally do okay. But to deliberately manipulate the diet so that weight gains are minuscule or non-existent? Unwise.

Too many care providers have jumped on the minuscule weight gain bandwagon because of the publicity push promoting it before these protocols were examined adequately for harm.

The Metformin Study

A similar questionable publicity campaign surrounded the British study using metformin to hopefully lower birth weights in babies of obese women. Some publicity articles used scare tactics and hyperbole about pregnancy risks in obese women to justify using this medication experimentally and implied that taking metformin would keep "overweight" women from having "overweight" babies. Basically, it was implied that obese women would be irresponsible if they didn't comply with this experiment.

The study had other issues; it used birthweight as a surrogate marker for the future ill-health of obese mothers' offspring. To me this is a very questionable assumption, since it is difficult to untangle cause and effect of metabolic issues like PCOS, lipedema, thyroid disturbances, and genetic contributions to a child's health vs. birthweight alone. In addition, big babies don't automatically become unhealthy adults, and there is plenty of evidence that too-small babies have more health problems than bigger ones.

The publicity campaign fanned the anti-obesity hysteria in the U.K., created a climate where women in the study probably felt they had little choice about taking such drugs (even though their use in this context was experimental), and created an expectation among care providers that metformin was the standard of care even in the pregnancies of non-diabetic obese women.

So I didn't love the premise of the study or the means by which they pressured women into it, even though I thought it would be interesting to see if metformin had an effect on birthweight.

Well, the study results are in, and metformin did NOT reduce birthweight among obese mothers. Birthweights were similar between the metformin and placebo groups. The ponderal index (a measure of length and weight, kind of like a BMI for babies) was similar between groups as well. In other words, metformin not only didn't lower average birthweight, it didn't make the babies any skinnier for their lengths either.

Nor did metformin improve other outcomes of pregnancy in obese women. The metformin group did not have lower prenatal weight gains, nor did they have fewer cesareans.

Basically, the researchers could not show any meaningful improvements in outcome from taking metformin.

There were a few minor differences between groups that did not rise to statistical significance. The metformin group did develop fewer cases of gestational diabetes, but only marginally. There were some small improvements in blood sugar and insulin in the metformin group at 28 weeks, but not at 36 weeks. Some inflammatory markers were lessened but the significance of this is unclear and didn't seem to have any bearing on immediate outcomes.

The metformin group did develop more pregnancy-induced hypertension, pre-eclampsia, and pre-term birth, but again only marginally. The difference did not rise to statistical significance.

Interestingly, there was a stronger tendency towards more poor outcomes (miscarriage, termination, stillbirth, or neonatal death) among the metformin group (3% vs. 1%), but the confidence interval crossed 1.0 and these results could have been mere coincidence rather than a real result of metformin. Given the rarity of such poor outcomes, the study group probably was not large enough to determine whether a real relationship between metformin and poor outcomes in non-diabetic mothers exists. In the study's defense, the description of the poor outcomes does not seem to indicate that they were due to metformin. The bottom line is that the study did not find a statistically significant increase in poor outcomes among those taking metformin.

It IS important to note that metformin is probably a relatively safe drug to use in pregnancy and is used with significant benefit in some diabetic mothers and women with PCOS, but its safety and efficacy in other mothers is less established.

Now we know that it really doesn't lower the birthweight of babies nor improve other outcomes in non-diabetic high BMI mothers. That led the study authors to conclude:
Metformin should not be used to improve pregnancy outcomes in obese women without diabetes.
Further Details

The fact that the study found no real benefit from metformin use in non-diabetic obese women disproved the authors' hypothesis that metformin would improve outcomes. However, the study's authors speculate that an impact on birthweight was not seen because of several possibilities.

First, the medication was not started until 12-16 weeks, rather than early in pregnancy or pre-conception. They theorized that perhaps the programming of fetal size takes place so early that starting it at 12-16 weeks was too late. However, since most women aren't seen in pregnancy until the end of the first trimester, it is unlikely most obese pregnant women would be able to be started earlier anyhow.

Second, they wondered if the doses may not have been high enough to be effective. They started at 500 mg per day and slowly increased the dosage until the "maximum tolerable dose" was reached ─ i.e., until woman experienced too many side effects like nausea, vomiting, diarrhea to tolerate continuing to increase the dose. Still, about 2/3 of the metformin arm received 2000 mg, very near the maximum dosage of 2500 mg, so the argument that the dose wasn't high enough is weak. This was an adequate test.

Third, the authors speculate that the real benefits of taking metformin during the fetal period would likely show in other ways as the child grew up instead of affecting birthweight. They cite an animal study that suggests less visceral fat in the offspring of mothers that received metformin during gestation. As a result, they are planning a follow-up study to monitor metformin-exposed children and see if they have less obesity and/or metabolic issues as they grow up.

This last theory is one that a lot of doctors are fixating on. This is the idea of fetal programming, that the window of time during gestation is one in which fat women "program" their babies to be larger and to have poorer long-term health, and therefore we needed to be extremely proactive about intervening in the pregnancies of obese women. One commentator noted:
The bold idea that what we do to the fetus during the short and finite period of pregnancy could change and even improve lifelong outcomes of offspring validates the whole concept of prenatal care. If this concept is true, this tiny window of opportunity should not be wasted.
This is an alarming statement to me. Yes, if we could change things during the fetal period that would improve that child's health long-term, that would be an exciting possibility. However, the potential for abuse here is quite high. I worry that researchers are SO excited about "preventing" obesity that their common sense will go out the window and they will start using even more scorched-earth ─ and unproven ─ tactics.

What if we intervene and change the child's long-term health negatively? I worry that scorched-earth protocols to get smaller babies through gestational weight loss or medications may actually backfire and create ripples those care providers don't anticipate. Where are the safety protocols to ensure lack of harm from such interventions?

The in-utero time is a powerful time, it's true. But that means we must be very VERY careful in how we intervene, if we intervene at all. And we certainly shouldn't be publicizing a particular approach until it has been proven both beneficial and harmless.


Big mothers tend to have bigger babies on average. This leads many care providers to institute major interventions and scorched-earth protocols to lower birth weight.

The most common intervention is to limit prenatal weight gain. While women of size probably need to gain less weight in pregnancy than other women, how much weight they should (or shouldn't) gain is more controversial. Even more controversial is what should be done to try to achieve that lower gain.

Too much weight gain is clearly linked to larger babies, and perhaps to other poor outcomes. As a result, many care providers have pushed to see the 2009 guidelines reduced even further. However, as noted, too-small gains during pregnancy have unacceptable trade-offs in more too-small babies and premature births. The harms are not worth the potential benefits.

Similarly, some care providers have begun to promote the idea of putting non-diabetic obese women on metformin prophylactically to try to prevent big babies. Although this can modestly reduce birthweight in women with gestational diabetes or full-blown diabetes, this study shows that metformin does not reduce birthweight in non-diabetic obese women.

This research effectively disproves the Pederson Hypothesis, which is that big babies are the result of maternal high blood sugar and responding high insulin levels in the baby. Although this feedback loop can cause fetal overgrowth in diabetic women, this study shows that higher birthweights in non-diabetic obese women are NOT because of borderline high blood sugar. There must be something else going on here to cause the bigger babies, which is something I've been saying for years. The authors suspect high lipid levels, but I'm dubious about that one too. Whatever the mechanism is, it's important to go cautiously and avoid jumping to conclusions based only on assumptions about fat people.

This study shows that metformin does not improve outcomes in non-diabetic obese women and should NOT be used for that purpose. Too bad the publicity push around the trial has already created a market for this, and some providers are pushing its use for all their obese patients. Two more trials like this one are already occurring.

Sadly, even though this research was completed and published this past summer, the trial's publicity website has not been updated to show the negative study results or conclusion. Although a bit of publicity about the negative findings has appeared in some medical publications, a large publicity push does not appear to have been done. How many care providers all over the world still have the impression that metformin should be the standard of care of obese women, regardless of blood sugar status?

Researchers, stop promoting a particular approach before the research is even done. A management protocol needs to be proven to be effective and safe in multiple trials before it should be publicized and promoted. Duh.

At least now we know that metformin, while helpful under certain circumstances, is not a cure-all for preventing complications in all high-BMI women or for preventing big babies. Care providers need to restrict its use to situations where it's actually appropriate and needed.


Lancet Diabetes Endocrinol. 2015 Oct;3(10):778-86. doi: 10.1016/S2213-8587(15)00219-3. Epub 2015 Jul 9. Effect of metformin on maternal and fetal outcomes in obese pregnant women (EMPOWaR): a randomised, double-blind, placebo-controlled trial. Chiswick C1, Reynolds RM2, Denison F1, Drake AJ2, Forbes S2, Newby DE3, Walker BR2, Quenby S4, Wray S5, Weeks A5, Lashen H6, Rodriguez A7,Murray G7, Whyte S1, Norman JE8. PMID: 26165398  Full text available here.
BACKGROUND: Maternal obesity is associated with increased birthweight, and obesity and premature mortality in adult offspring. The mechanism by which maternal obesity leads to these outcomes is not well understood, but maternal hyperglycaemia and insulin resistance are both implicated. We aimed to establish whether the insulin sensitising drug metformin improves maternal and fetal outcomes in obese pregnant women without diabetes. METHODS: We did this randomised, double-blind, placebo-controlled trial in antenatal clinics at 15 National Health Service hospitals in the UK. Pregnant women (aged ≥16 years) between 12 and 16 weeks' gestation who had a BMI of 30 kg/m(2) or more and normal glucose tolerance were randomly assigned (1:1), via a web-based computer-generated block randomisation procedure (block size of two to four), to receive oral metformin 500 mg (increasing to a maximum of 2500 mg) or matched placebo daily from between 12 and 16 weeks' gestation until delivery of the baby...FINDINGS: Between Feb 3, 2011, and Jan 16, 2014, inclusive, we randomly assigned 449 women to either placebo (n=223) or metformin (n=226), of whom 434 (97%) were included in the final modified intention-to-treat analysis. Mean birthweight at delivery was 3463 g (SD 660) in the placebo group and 3462 g (548) in the metformin group. The estimated effect size of metformin on the primary outcome was non-significant (adjusted mean difference -0·029, 95% CI -0·217 to 0·158; p=0·7597). The difference in the number of women reporting the combined adverse outcome of miscarriage, termination of pregnancy, stillbirth, or neonatal death in the metformin group (n=7) versus the placebo group (n=2) was not significant (odds ratio 3·60, 95% CI 0·74-17·50; p=0·11).  INTERPRETATION: Metformin has no significant effect on birthweight percentile in obese pregnant women. Further follow-up of babies born to mothers in the EMPOWaR study will identify longer-term outcomes of metformin in this population; in the meantime, metformin should not be used to improve pregnancy outcomes in obese women without diabetes