Common Sense Prenatal Weight Gain Recommendations for "Obese" Women

The 2009 IOM Guidelines for Prenatal Weight Gain

Coming up with official prenatal weight gain guidelines is difficult. There's always a trade-off involved ─ too much weight gain increases the risk for large babies, but too little increases the risk for small babies.

(The effects of weight gain on cesarean rates and pre-eclampsia are harder to figure out because of multiple variables that influence outcomes, so we will limit our discussion for a moment to the influence of weight gain on fetal outcomes.)

This weight gain trade-off has been particularly difficult to figure out in women of size. We tend to have larger babies on average and a very big weight gain seems to increase fetal size particularly strongly in high-BMI women. Nor do we need to gain extra fat reserves for pregnancy and breastfeeding. As a result, the Institute of Medicine (IOM) recommends less weight gain on average for "obese" women (see chart above).

While I don't hate these recommendations, I do have some concerns with them, particularly for women in the borderline categories (see discussion below). Women in these categories may be particularly at risk for poor outcomes, yet they are given the same stringent guidelines (and are often told to gain even less than the guidelines).

I also question how much control women really have over gestational weight gains. Sure, we have control over how much we eat and exercise, but that impact on gain is fairly minimal. There have been many trials of interventions to help obese women keep their weight gains lower; some have had minimal success (about 5 lbs. difference), but many have made little difference in weight gain and do little to improve other outcomes. Even with the best support, many women of size gain above the guidelines ─ not because they are lazy or out of control, but because the guidelines aren't particularly realistic for them.

I am also concerned about harassment and over-intervention in the pregnancies of women who gain above these recommended ranges. I have heard many stories of women of size who are harassed or even punished with early inductions or planned cesareans because they "gained too much."

So while I agree in general with the IOM that obese women don't need to gain as much weight in pregnancy as other women, I do have some reservations about the IOM guidelines and in particular about how they are implemented. But sadly, even these guidelines are not stringent enough for some providers.

Taking The 2009 Guidelines Even Further

Some caregivers believe the 2009 IOM weight gain goals didn't go far enough for obese women. In recent years, unofficial prenatal weight gain advice has gotten progressively more extreme. I call this the "anorexation" of pregnancy weight gain guidelines.

The following are real-life headlines from media articles over the years. Notice how the headlines have changed. They have gone from "obese women should gain LESS weight".....

...to "obese women should gain NO weight"

....to "obese women should LOSE weight" during pregnancy.

Disturbingly, many experts have taken an extremist tone in the media and sold these draconian measures as a public health imperative, which alarms me greatly. Many news articles have pushed this weight restriction agenda, assuring us that very little gain was perfectly safe and even healthier for the plus-sized mother and her baby. Here are just a couple of examples.

One article about the IOM recommendations prominently featured the following quotes promoting even lower gains in high-BMI women:

"I think 11 to 20 pounds is way too much for an obese woman," said Dr. Thomas Myles, a professor of obstetrics and gynecology at Saint Louis University School of Medicine who was not involved in the current recommendations. "I usually tell my [obese] patients that gaining less than 10 pounds and even losing up to 10 pounds is appropriate, whereas for overweight women, gaining 10 to 15 and even up to 20 pounds is appropriate," Myles said. 

Gaining a little less weight than the recommended amount, especially for overweight and obese women, might be better, [Associate Professor, Dr. Emily] Oken [of Harvard University] said.

Another article promoting zero weight gain in obese women featured the following quote from one of its leading investigators in its study's press release (my emphasis):

It may seem counterintuitive to suggest that women control their weight during pregnancy, but these women are already carrying between 50 and 100 extra pounds — and for them any more weight gain could be very dangerous,” said Vic Stevens, PhD, principal investigator who has studied weight loss and weight maintenance for more than 30 years.

Another recent article quoted Dr. Sigal Klipstein, Chair of the American College of Obstetricians and Gynecologists committee on Medical ethics. Even as she discussed the importance of treating obese women humanely during pregnancy, Dr. Klipstein stated:

Although women should not to try to lose weight during pregnancy, “a woman who weighs 300 pounds shouldn’t gain at all,” Klipstein said. “This is not harmful to the fetus.”

But is it really true that very small or non-existent gains are not harmful?

Risks of Too-Small Gains

Those who suggest that gaining little or no weight is optimal for women of size are ignoring all the contrary research.

A significant amount of research has shown that very low weight gains and/or weight loss during pregnancy in women of size carries real risks, including

• prematurity (Dietz 2006, Potti 2010, Hasegawa 2012)
• too-small babies (Vesco 2011, Catalano 2014)
• more need for intensive care in the NICU (Potti 2010)

Tellingly, virtually NO media articles acknowledge that low weight gains have risks or cite the research that shows this. That there are so many articles promoting restricted gain in obese women while completely ignoring the potential harms of such a policy suggests a health agenda that places ideology over evidence.

And now there is even more research suggesting that very low gains may be risky.

A very recent study (Durst 2016) showed that weight gains below the IOM recommendations in obese women led to increased rates of  small-for-gestational-age ("SGA") babies and pre-term births. Another recent study (Cox Bauer 2016) found that gestational weight loss (GWL) was associated with low-birth weight babies. These are a concern because too-small babies are more at risk for future health problems like metabolic syndrome and insulin resistance.

Still another recent study (Hannaford 2016) shows that too-low weight gains, even in obese women, more than doubled the risk for too-small babies. The authors suggested that there may need to be a threshold of a minimum weight gain, even for very high-BMI women, which is a pretty radical suggestion given how many doctors are calling for zero gain or weight loss in this group.

But these new studies are far from the first to find reasons for concern. A brand-new meta-analysis (Xu 2017) of studies on weight gain below the 2009 guidelines in obese mothers found that low weight gain was associated with SGA babies in all obesity categories, not just in the borderline categories.

Yet another meta-analysis (Kapadia 2015) of studies on weight gain in obese pregnant women concluded that, because of its consistent association with too-small babies,

Gestational weight gain below the guidelines cannot be routinely recommended.

Too-small babies and prematurity may not be the only risks of very low weight gains; they may also be implicated in infant deaths.

A recent study (Bodnar 2016) found that weight loss and very low weight gains in Class I and II obese women were associated with a higher risk of infant death.

This is particularly important because research is very clear that SGA babies have a higher risk for stillbirth and neonatal mortality. In addition, some past research (Salihu 2009) shows that SGA babies of obese women are at particular risk for stillbirth.

Sorry, but SGA babies, prematurity, and infant death are pretty significant concerns. People like Dr. Myles, Dr. Oken, Dr. Stevens, and Dr.Klipstein who have been recommending weight gains well below the IOM recommendations have been playing Russian Roulette with the babies of their patients of size.

This is a common problem in medicine ─ taking a recommendation to extreme lengths without adequately studying its safety first.

Obese women as a group may benefit from gaining less weight on average than other women, but it does NOT automatically follow that even less is better. 

Sadly, while now there are years of data suggesting harms with very low gains and/or gestational weight loss, many experts are STILL telling women of size and their providers that "any weight gain in overweight and obese patients is detrimental to pregnancy outcome." Any weight gain, really?

This bias towards ever-lowered weight gain goals is so ingrained that it continues to deny the existence of any contrary evidence. The 2013 article quoted above advises OB-GYNs:

Weight maintenance and even weight reduction have not proven harmful in obese pregnant patients according to studies in the recent literature

Not proven harmful? This statement completely ignores numerous studies published before 2013 pointing out safety concerns with this advice (Bayerlein 2011, Bodnar 2010, Blomberg 2011, Vesco 2011, Dietz 2006, Potti 2010, Hasegawa 2012).

And now we have EVEN MORE studies showing that there are safety concerns, yet this low/no gain/weight loss advice continues to be given routinely by many providers who assure their patients falsely that there is no reason to worry.

But What About....?

Critics will undoubtedly point out that some of these same studies show benefits of lower gains such as a modestly lower cesarean rate or lower rates of pre-eclampsia. These are valid points. However, that's a whole different discussion because multiple variables influence these complications and it's difficult to tease out a causal relationship.

For example, caregivers are not blinded to their patients' gains. A bigger gain may mean a bigger baby. Fear of a big baby can strongly influence the perception of when a cesarean is "needed" and how many interventions like induction are used. Research shows that women with larger weight gains are induced at higher rates. Therefore it may not be weight gain that's the issue, but rather how the caregiver responds to the gain.

Pre-eclampsia is another situation where you can't jump to conclusions about weight gain. Women with pre-eclampsia typically have a lot of swelling, which means a higher weight gain. As Nohr 2008 states:

Any causal interpretation of the association between total weight gain and these complications is limited. For preeclampsia, high total gain most likely reflects pathologic fluid retention as part of the disease.

In other words, a higher weight gain doesn't necessarily cause pre-eclampsia, but rather it often results from pre-eclampsia. It certainly doesn't mean that a lower weight gain will prevent pre-eclampsia. We just don't know if deliberately restricting weight gain will lower the rate of pre-eclampsia in obese women.

However, it must be acknowledged that too much weight gain is probably also not ideal. Prenatal weight gain clearly influences fetal size, and higher gains seem particularly particularly potent for larger fetal size in high-BMI women. Postpartum, a larger gain may also be difficult to lose; multiple pregnancies with large gains can result in a net overall weight increase that might possibly affect the mother's health. So doctors have to find a balance between the very real risk/benefit trade-offs of too much or too little gain in pregnancy.

That's not easy, and I acknowledge that. But it seems to me that the debate is still very unbalanced, with too many experts still not willing to acknowledge the very real risks of too-small gains.

Deliberately ignoring contrary research is not an evidence-based approach. It smacks of a weight restriction agenda instead of a reasoned approach to best practices.

Summary

For too long, "experts" have been waging a campaign to lower the 2009 IOM guidelines even further for obese women. As a result, many care providers have used draconian pressure on women of size to gain very little or even to lose weight in pregnancy. But there are significant safety concerns with this approach, concerns that these so-called experts are conveniently ignoring.

The research makes several things clear:

1. Very low weight gain or weight loss is extremely consistent with too-small babies in multiple studies 
2. Too-small babies are at increased risk for adulthood diseases
3. Weight loss and very low weight gains may also be associated with a higher risk for infant death and prematurity 

These concerns means it's time for caregivers to STOP promoting extreme weight gain limits and to START acknowledging that very low gains also carry risks. 

Now, it may be that in time, different weight gains will be recommended for different levels of obesity. That seems like a possibility that is worthy of further consideration.

For example, "overweight" women (BMI 25-29) and women with Class I obesity (BMI 30-35) seem to be the most negatively affected by very small weight gains, whereas some research shows that women with Class III obesity (BMI 40-50) and Class IV obesity (BMI 50+) are less affected on average by very low gains.

So there may be some gradations in recommendations in the future, and I welcome discussions about this possibility ─ but given the established risks and the meta-analysis of studies that showed increased SGA risks across all class sizes of obesity, it would still behoove us to be very cautious about recommending very low weight gain even in women with Class III and IV obesity. We simply cannot assume that restricting gains is harmless even there.

Common Sense Recommendations

To me, what's missing from prenatal weight gain recommendations for obese women is nuance. It's time to pull back from prenatal weight gain extremism and show some common sense. Here are the things I think caregivers should take into account when discussing pregnancy weight gain with women of size.

Women of size should be informed in a neutral way of the IOM weight gain recommendations and why they were made. A neutral discussion, with research citations as appropriate, goes a lot further to helping women make informed and empowered decisions. A decision about weight gain goals that comes from the woman herself, rather than being imposed by external forces, is a lot more likely to result in reasonable gains.

How the message is communicated is important. Women should be given reasonable nutritional advice and strongly encouraged to exercise, but risks should not be exaggerated. Lecturing, scare tactics, and condescension means that people will simply tune out recommendations. Treat women as competent partners in their own care and avoid judgment. Emphasize healthy habits rather than numbers on the scale.

Consider tailoring recommendations by BMI. Women in the borderline BMI classes are the most at risk for poor outcomes with very low gains; they should be encouraged to gain nearer to the top of the IOM recommendations. It may even be that women with Class I obesity (BMI 30-35) do best with slightly more gain (15-25 lbs.). Women in Class III (BMI over 40) and Class IV obesity (BMI over 50) can be encouraged to gain towards the lower end of the recommendations or even slightly lower (5-15 lbs.) but great care should be taken that this message does not translate into pressure for restricted intake or extreme measures. Do not assume that very high BMI women have adequate nutritional reserves to make up for a lack of gain; good nutrition is always the priority.

Do not promote actively losing weight in pregnancy. Research shows there are too many potential harms to recommend pursuing gestational weight loss. Some women of size lose without trying; this is not a cause for panic as long as intake is adequate and the baby is growing well. But actively encouraging women to aim for weight loss during pregnancy is different than coincidental weight loss, is likely to result in restrictive behaviors, and probably has far greater risk.

Consider patterns of gestational weight gain. Has the weight gain pattern been relatively smooth? Was there a very large gain in the beginning? At the end? Different patterns may indicate different concerns. Also, don't forget to take pre-conception weight into account; many obese women lose weight in the first trimester and slowly gain that back to a small overall gain. If the initial loss is not counted, it looks like the woman has gained more weight than she actually has. Look at the whole picture.

Do not harass women about weight gain. Weight-related harassment is obnoxious and inappropriate, but it is sadly all too common. Women should not feel afraid to step on the scale at appointments, yet they often experience harassment. Medical assistants should record weight without comment. Care providers can ask neutrally about gains and can work with women on monitoring nutrition and troubleshooting worrisome trends, but judgment and belittling will only backfire. If a woman gains outside of guidelines despite good nutrition and regular exercise, consider other possible variables. Assume that a woman's body will gain what it needs for a healthy pregnancy.

Avoid food extremism. Women of size should not be pressured to strongly restrict calories or to eliminate entire food groups. They should be encouraged to eat reasonable amounts from a wide variety of foods. Nutritional advice should be evidence-based, not from unproven diet trends. Caregivers need to find a way to talk to clients about nutrition and weight gain concerns without condescension or judgment. Work with women and listen to their feedback about their needs.

Individualize care according to the woman's needs. People of size are not all alike. Some fit stereotypical images of fast food consumption and binge eating, others have very healthy habits, and many fall somewhere in between. Ask them respectfully about their habits and concerns; don't make assumptions. Believe what they tell you and advise them accordingly. If habits need improvement, encourage small and reasonable steps and recognize positive achievements.

Remember that weight gains among high-BMI women are highly variable. Research shows that weight gains in pregnancy are less predictable in larger women. Some have very large gains, some have very small gains, and some lose weight without trying. Often the women who gain the most are those who have recently lost weight or who are chronic dieters/weight cyclers, those with lipedema, or those who have swelling with pre-eclampsia. Many factors influence gestational weight gain besides the habits of the women. Acknowledge that some weight gain may be out of their control.

Look more at how the mother and baby are doing than at the scale. Guidelines are more for groups than individuals. While research shows that very high or very low gains are generally best avoided on average, some obese women gain more or less than recommended and have perfectly healthy babies. Some gain a lot and have average-sized babies; some gain almost nothing and have big babies; some lose weight with no obvious harmful effect. Gaining outside the recommendations is not necessarily a cause for alarm, as long as the mother's intake is normal and baby is growing well.

Women should not be subjected to extra interventions if they exceed their providers' weight gain goals. Some fat women are being consciously punished for "too much weight gain" by being subjected to extra interventions like inductions or planned cesareans. However, some of these interventions may occur because of providers' underlying fears about big babies. Care providers must actively examine their own biases so that they do not unconsciously use increased interventions on those who gain more.

Most importantly, focus on nutrition rather than on the scale. Too many providers use weight gain as a marker of pregnancy status and ignore nutrition altogether. What a woman is eating matters more than how much weight she has gained. Women can be given a weight gain goal range, nutritional advice, and exercise opportunities, but nutrition should not be manipulated in order to achieve an arbitrary number. The scale is a poor predictor of outcome and should not be used as a surrogate for nutritional adequacy or fetal status. Focus more on nutrition and concrete signs of how the mother/baby dyad is doing than on numbers on a scale.

Care providers need to bring common sense back into prenatal weight gain guidelines and take a more nuanced approach with women of size.


References

Very Low Gain and Too-Small Infants (Latest Studies)

Am J Perinatol. 2016 Jun 29. [Epub ahead of print] Gestational Weight Gain: Association with Adverse Pregnancy Outcomes. Hannaford KE1, Tuuli MG, Odibo L, Macones GA, Odibo AO. PMID: 27355980 DOI: 10.1055/s-0036-1584583

...OBJECTIVES: We investigated how weight gain outside the IOM's recommendations affects the risks of adverse pregnancy outcomes. STUDY DESIGN: We performed a secondary analysis of a prospective cohort study including singleton, nonanomalous fetuses. The risks of small for gestational age (SGA), macrosomia, preeclampsia, cesarean delivery, gestational diabetes, or preterm birth were calculated for patients who gained weight below or above the IOM's recommendations based on body mass index category....Women who gained weight below recommendations were 2.5 times more likely to deliver SGA and twice as likely to deliver preterm...Obese patients who gained inadequate weight were 2.5 times more likely to deliver SGA. CONCLUSIONS: ...Among obese patients, a minimum weight gain requirement may prevent SGA infants.

Am J Perinatol. 2016 Jul;33(9):849-55. doi: 10.1055/s-0036-1579650. Epub 2016 Mar 9. Impact of Gestational Weight Gain on Perinatal Outcomes in Obese Women. Durst JK, Sutton AL, Cliver SP, Tita AT, Biggio JR. PMID: 2696070

...STUDY DESIGN: A retrospective cohort of perinatal outcomes in obese women who gained below, within, or above the 2009 Institute of Medicine guidelines and delivered ≥ 36 weeks. Additionally, outcomes, according to the rate of GWG (kg/week; minimal [< 0.16], moderate [0.16-0.49], or excessive [> 0.49]) were compared among women delivering preterm. RESULTS: Overall, 5,651 obese women delivered ≥ 36 weeks. GWG above guidelines was associated with increased cesarean section (adjusted odds ratio [aOR]: 1.44, 95% confidence interval [CI]: 1.21-1.72), gestational hypertension (aOR: 1.58, 95% CI: 1.21-2.06), and macrosomia (birth weight ≥ 4,000 g) (aOR: 2.08, 95% CI: 1.62-2.67). GWG below recommendations was associated with less large for gestational age infants (aOR: 0.60, 95% CI: 0.47-0.75)...Minimal weekly GWG was associated with increased spontaneous preterm birth (aOR: 1.56, 95% CI: 1.23-1.98) and more small for gestational age (SGA) infants (aOR: 1.55, 95% CI: 1.19-2.01). Excessive weekly GWG was associated with increased indicated preterm birth (aOR: 1.61, 95% CI: 1.29-2.01), cesarean section (aOR: 1.39, 95% CI: 1.20-1.61), preeclampsia (aOR: 1.83, 95% CI: 1.49-2.26), neonatal intensive care unit admission (aOR: 1.33, 95% CI: 1.08-1.63), and macrosomia (aOR: 2.40, 95% CI: 1.94-2.96).CONCLUSIONS: Obese women with excessive GWG had worse outcomes than women with GWG within recommendations. Limited GWG was associated with increased spontaneous preterm birth and SGA infants.

J Perinatol. 2016 Apr;36(4):278-83. doi: 10.1038/jp.2015.202. Epub 2016 Jan 7. Maternal and neonatal outcomes in obese women who lose weight during pregnancy. Cox Bauer CM, Bernhard KA, Greer DM, Merrill DC. PMID: 26741574

OBJECTIVE: To evaluate neonatal and maternal outcomes in obese pregnant women whose weight gain differed from the Institute of Medicine (IOM) recommendations. STUDY DESIGN: Maternal and neonatal outcomes associated with weight change in pregnancy were retrospectively investigated in women with obesity (body mass index (BMI) ⩾30 kg m(-2); N=10734) who gave birth at 12 hospitals...RESULT: Compared with IOM recommendations, weight loss was associated with twofold greater odds of low birth weight infants and a mean decrease in estimated blood loss of 30 ml; excessive weight gain was associated with doubled odds of gestational hypertension or preeclampsia, fourfold greater odds of macrosomia and a mean decrease in 5-min APGAR of 0.09....

J Matern Fetal Neonatal Med. 2017 Feb;30(3):357-367. Epub 2016 Apr 28. Inadequate weight gain in obese women and the risk of small for gestational age (SGA): a systematic review and meta-analysis. Xu Z, Wen Z, Zhou Y, Li D, Luo Z. PMID: 27033234

...We conducted a meta-analysis of original researches with sufficient information about inadequate GWG in obese women stratified by obesity classes. SGA as the chief outcome was extracted and assessed in our analysis...13 studies (437 512 obese women) were included. Obese women who gained weight below the guidelines had higher risks of SGA than those who gained weight within the guidelines (OR 1.28; 95% CI 1.14-1.43). The same conclusions were also confirmed in Class I, Class II and Class III of obese women: Class I (OR 1.37; 95% CI 1.22-1.54); Class II (OR 1.38; 95% CI 1.24-1.54); Class III (OR 1.25; 95% CI 1.14-1.36). CONCLUSIONS: From our analysis, the guidelines of IOM can be applied to all the classes of obesity. More accurate boundaries for each obesity class should be established to evaluate the maternal and fetal risks. Diverse populations are thus necessary for more studies in the future.

Low Weight Gain/SGA and Risk for Infant Death 

Obesity (Silver Spring). 2016 Feb;24(2):490-8. doi: 10.1002/oby.21335. Epub 2015 Nov 17. Maternal obesity and gestational weight gain are risk factors for infant death. Bodnar LM, Siminerio LL, Himes KP, Hutcheon JA, Lash TL, Parisi SM, Abrams B. PMID: 26572932

OBJECTIVE: Assessment of the joint and independent relationships of gestational weight gain and prepregnancy body mass index (BMI) on risk of infant mortality was performed. METHODS: This study used Pennsylvania linked birth-infant death records (2003-2011) from infants without anomalies born to mothers with prepregnancy BMI categorized as underweight (n = 58,973), normal weight (n = 610,118), overweight (n = 296,630), grade 1 obesity (n = 147,608), grade 2 obesity (n = 71,740), and grade 3 obesity (n = 47,277)...For all BMI groups except for grade 3 obesity, there were U-shaped associations between gestational weight gain and risk of infant death. Weight loss and very low weight gain among women with grades 1 and 2 obesity were associated with high risks of infant mortality....

Am J Perinatol. 2016 Aug 17. [Epub ahead of print] Morbidity and Mortality in Small-for-Gestational-Age Infants: A Secondary Analysis of Nine MFMU Network Studies. Mendez-Figueroa H1, Truong VT2, Pedroza C2, Chauhan SP1. PMID: 27533102

...Data from nine Maternal-Fetal Medicine Units Network studies were used and included nonanomalous singletons at 24 weeks or more and birth weight < 90% for EGA...Among SGA, the likelihood of stillbirth (8.8 vs. 2.5 per 1,000 births; adjusted odds ratio [aOR] 3.98, 95% confidence interval [CI]: 2.92-5.42) and neonatal mortality (14.0 vs. 5.5 per 1,000 births; aOR 3.18, 95% CI: 2.55-3.95) was threefold higher compared with AGA. For the subgroup of newborns of EGA of 32 weeks or more, SGA, compared with AGA, had significantly higher risk of stillbirth (aOR 3.32, 95% CI: 2.16-5.12) and neonatal mortality (aOR 2.50; 95% CI: 1.38-4.54). From 35 weeks onward, the risk of stillbirth among SGA is almost four times higher than for AGA. CONCLUSION: The risk of stillbirth and neonatal mortality is significantly higher with SGA than with AGA. Modification in practice or new management schema may be warranted.

Obstet Gynecol. 2009 Aug;114(2 Pt 1):333-9. Success of programming fetal growth phenotypes among obese women. Salihu HM, Mbah AK, Alio AP, Kornosky JL, Bruder K, Belogolovkin V. PMID: 19622995

...METHODS: This was a retrospective cohort study using the Missouri maternally linked cohort files (years 1978-1997)...Fetal growth phenotypes were defined as large for gestational age (LGA), appropriate for gestational age (AGA), and small for gestational age (SGA)...Neonatal mortality among LGA infants was similar for obese...and normal...weight mothers (OR 1.05, 95% confidence interval [CI] 0.75-1.48) and regardless of obesity subtype. By contrast, SGA and AGA infants programmed by obese mothers experienced greater neonatal mortality as compared with those born to normal weight mothers (AGA OR 1.45, 95% CI 1.32-1.59; SGA OR 1.72, 95% CI 1.49-1.98). CONCLUSION: Compared with normal weight mothers, obese women are least successful at programming SGA, less successful at programming AGA, and equally as successful at programming LGA infants.

Low Weight Gain and Risk for Prematurity

Obesity (Silver Spring). 2013 Dec;21(12):E770-4. doi: 10.1002/oby.20490. Epub 2013 Jul 5. Gestational weight loss and perinatal outcomes in overweight and obese women subsequent to diagnosis of gestational diabetes mellitus. Yee LM, Cheng YW, Inturrisi M, Caughey AB. PMID: 23613187

...Retrospective cohort study of 26,205 overweight and obese gestational diabetic women enrolled in the California Diabetes and Pregnancy Program. Women with GWL [Gestational Weight Loss] during program enrollment were compared to those with weight gain...RESULTS: About 5.2% of women experienced GWL. GWL was associated with decreased odds of macrosomia (aOR 0.63, 95% CI 0.52-0.77), NICU admission (aOR 0.51, 95% CI 0.27-0.95), and cesarean delivery (aOR 0.81, 95% CI 0.68-0.97). Odds of SGA status (aOR 1.69, 95% CI 1.32-2.17) and preterm delivery <34 weeks (aOR 1.71, 95% CI 1.23-2.37) were increased. CONCLUSIONS: In overweight and obese women with GDM, third trimester weight loss is associated with some improved maternal and neonatal outcomes, although this effect is lessened by increased odds of SGA status and preterm delivery. Further research on weight loss and interventions to improve adherence to weight guidelines in this population is recommended.

BJOG. 2011 Jan;118(1):55-61. doi: 10.1111/j.1471-0528.2010.02761.x. Epub 2010 Nov 4. Associations of gestational weight loss with birth-related outcome: a retrospective cohort study. Beyerlein A, Schiessl B, Lack N, von Kries R. PMID: 21054761

...DESIGN: Retrospective cohort study. SETTING AND POPULATION: Data on 709 575 singleton deliveries in Bavarian obstetric units from 2000-2007 were extracted from a standard dataset for which data are regularly collected for the national benchmarking of obstetric units...RESULTS: GWL was associated with a decreased risk of pregnancy complications, such as pre-eclampsia and nonelective caesarean section, in overweight and obese women [e.g. OR = 0.65 (95% confidence interval: 0.51, 0.83) for nonelective caesarean section in obese class I women]. The risks of preterm delivery and SGA births, by contrast, were significantly higher in overweight and obese class I/II mothers [e.g. OR = 1.68 (95% confidence interval: 1.37, 2.06) for SGA in obese class I women]. In obese class III women, no significantly increased risks of poor outcomes for infants were observed. CONCLUSIONS: The association of GWL with a decreased risk of pregnancy complications appears to be outweighed by increased risks of prematurity and SGA in all but obese class III mothers.

Epidemiology. 2006 Mar;17(2):170-7. Combined effects of prepregnancy body mass index and weight gain during pregnancy on the risk of preterm delivery. Dietz PM, Callaghan WM, Cogswell ME, Morrow B, Ferre C, Schieve LA. PMID: 16477257

...METHODS: Using data from the Pregnancy Risk Assessment Monitoring System in 21 states, we estimated the risk of very (20-31 weeks) and moderately (32-36 weeks) preterm delivery associated with a combination of prepregnancy body mass index (BMI) and gestational weight gain among 113,019 women who delivered a singleton infant during 1996-2001...RESULTS: There was a strong association between very low weight gain and very preterm delivery that varied by prepregnancy BMI, with the strongest association among underweight women (adjusted odds ratio = 9.8; 95% confidence interval = 7.0-13.8) and the weakest among very obese women (2.3; 1.8-3.1)...Women with very high weight gain had approximately twice the odds of very preterm delivery, regardless of prepregnancy BMI. CONCLUSIONS: This study supports concerns about very low weight gain during pregnancy, even among overweight and obese women, and also suggests that high weight gain, regardless of prepregnancy BMI, deserves further investigation.

J Matern Fetal Neonatal Med. 2012 Oct;25(10):1909-12. doi: 10.3109/14767058.2012.664666. Epub 2012 Mar 12. Gestational weight loss has adverse effects on placental development. Hasegawa J1, Nakamura M, Hamada S, Okuyama A, Matsuoka R, Ichizuka K, Sekizawa A, Okai T. PMID: 22348351

OBJECTIVE: To clarify whether mothers with gestational weight loss (GWL) were likely to have adverse effects on the placenta. STUDY DESIGN: Subjects who delivered viable singleton infants after 24 weeks of gestation were enrolled. A retrospective analysis to evaluate cases of GWL in association with the findings of the placenta and amniotic membrane after delivery was conducted. After consideration of confounders, a case-control study with matched pairs (1:2) was performed. RESULTS: Of all subjects (5551 cases), 83 cases (1.5%) with GWL were found. Since the pre-pregnancy maternal body mass index (BMI) was significantly higher in cases, 166 controls with a matched BMI were selected. The neonatal birth weights, placental weights and the umbilical cord length in cases were significantly smaller than in controls (p < 0.05). Preterm delivery and small for gestational age (SGA) infants were more frequently observed in cases compared with controls [odds ratio (OR) 6.3; 95% confidence interval (CI) 3.3, 12.1, OR 4.3; 95% CI 1.9, 9.9]. pPROM were observed in 10.8% of the cases and 1.8% of the control (OR 6.6; 95% CI 1.7, 25.1). However, the frequencies of chorioamnionitis and the cervical length at second trimester were not different between the two groups. CONCLUSION: GWL is associated with SGA, small placenta, short umbilical cord length, preterm delivery and pPROM.

Plea for Help in the U.K.

This comment was left on a recent post on this blog.  It is a plea for help from a pregnant women in the U.K.

I am only going to address one aspect of her concerns, the one I find most disturbing; I hope others will step up and address some of the rest of her concerns.

Please please please, can someone help me. I am 10 weeks pregnant and currently have a BMI of 35.  

Firstly, I have suffered with severe sickness since 5 weeks and doctor said it was ok as I 'could do with losing some weight' and refused to give me medications, and now I have had my first midwife appointment today and was told that more than 50 percent of maternal deaths in pregnancy and childbirth are obese mothers and that I will have to have special monitoring and won't be allowed to have a natural birth at the birth centre and will have to be under consultant care and be constantly monitored throughout labour (meaning no water birth, no moving around, no getting into positive positions to birth).  

I am so scared and disappointed, I feel like I am an unfit mother already and feel that the drs think I do not care about the health of my unborn baby. Now I know that this will not go down well with some people but I am considering a termination so that I can lose more weight before carrying a child (I have currently lost 70 pounds). 

I came across this blog and I am aware that you are based in the US and I am in the UK so some things are different...for instance I can't actually choose a provider and am stuck with who I have :(...but please, any advice would be so appreciated. Both myself and my partner are concerned and do not know what to do. 

There are so many things to cover here, it's hard to know where to start.  Please comfort and reassure this woman that she CAN do this.  She needs to hear from many people, not just me.  Please leave some encouraging comments at the end of this post.*

In the meantime, here is my response.  First, dear Reader, please don't terminate this pregnancy over these scare tactics or your fears.  Chances are that everything will be okay.  Many MANY women with a BMI well over 35 have had healthy pregnancies and babies.  My BMI is 48, far over yours, and I had 4 healthy pregnancies and babies, and am none the worse for wear for it. I know so many women your size and far larger who have had healthy happy babies.  You can read some of their birth stories here and here.

No, no one can promise you with 100% certainty that you and this baby will be fine, but the odds are certainly in your favor, "obese" or not. Most obese women have healthy babies; some do have complications like GD or high blood pressure, but even then, most of the time, these conditions are able to be treated and everyone is still fine.  So don't panic over the scare tactics they are giving you.

To be fair, the doctors and midwives are trying to do what they think is their job, to apprise you of possible risks associated with "obesity" and pregnancy, but the problem is that they have gone so far overboard in stating these that they are frightening women unduly, making them think that almost no women of size have healthy pregnancies or babies, when in fact, most do.

In some cases, care providers lay on the scare tactics so strongly that they bully women into weight loss surgery, risky diets, over-intervention, and even terminating the pregnancy.  That is NOT good health care, that's medical bullying. And for God's sake, this poor woman has already lost 70 lbs., but despite the fact that she followed typical medical advice to lower her BMI before pregnancy, she is still being punished and scared half to death.  Where is the justice in that?

Yes, there are some risks associated with pregnancy in obese women, but NO, the answer is not in scaring women into terminating an established pregnancy until they reach a "normal" BMI.

Shame on these providers for laying the scare tactics on so strongly that someone would even consider terminating a pregnancy simply because of their weight.

Yes, among those rare women who have died during pregnancy or birth, obese women are overrepresented somewhat.  That does NOT mean that 50% of obese women who are pregnant die during pregnancy─that's a misunderstanding of what the care providers were trying to say. Death is an extremely rare occurrence for childbearing women in the developed world, and although very high BMI women are somewhat overrepresented in that group, the actual numerical risk of it happening to any one obese woman is quite low.

And the reason why fat women do die during pregnancy or birth boils down to three main causes, some of which is preventable:

• Complications from general anesthesia during a cesarean
• Complications from hypertensive disorders (high blood pressure and resulting disorders) in pregnancy
• Blood clots (usually in conjunction with cesareans)

So to lower the risk for these problems, consider the following:

• Don't let them push you into a cesarean you don't need. If a cesarean is required at some point, make sure they are prepared to use an epidural or spinal block instead of general anesthesia. Have an anesthesia consult ahead of time to be sure they have the equipment needed on hand if it were needed
• Make sure you are monitoring your blood pressure carefully (you can get a home BP monitor if your readings are questionable at all), make sure they use the correct-sized BP cuff so that that readings are accurate, and get regular exercise and have great nutrition to lower your risk for developing gestational diabetes or blood pressure issues 
• Regular exercise also lowers the risk for a blood clot during pregnancy; for certain people, low-dose aspirin therapy (only under the supervision of a care provider) is sometimes advised. If you have a cesarean, discuss with your provider the use (and proper dosage) of blood thinners, and be sure to move your legs around and walk as early as you can tolerate after the surgery. There are also special wraps and cuffs that can help reduce your chances of a blood clot after a cesarean; make sure to request these if you have a cesarean, and note any increase in shortness-of-breath to your providers

If this woman were in the U.S., I'd tell her to change care providers ASAP because it's difficult to overcome a really deep-set provider bias about obesity in just a few months, and it often influences the care a high-BMI mother receives.  However, I'm not sure what your options are for alternatives in the U.K.

There are, of course, private midwives that you could hire from outside the NHS system, and it seems to me like this would be well worth the money to do if you can manage it.  I bet we could find a private midwife who would take you on as a client and who would work with you to find a way to make it financially feasible.  I know there have been women of size who have had great out-of-hospital births in the U.K. with private midwives.

But if that's absolutely not an option, then you will have to work within the system, and the way to do that is to push back against the care providers who are giving you a hard time.  I'm hoping some of my U.K. readers will pop in and leave some suggestions about how to do that.

At the very least, one of the best things you can do is to find a Pregnancy Buddy, an advocate familiar with size-friendly care practices, who will come with you to appointments and help you speak up for quality care and question fat-phobic practices.  A doula who really "gets" weight stigma and has a Health At Every Size approach could be a great help for you in advocating for more size-friendly care.

Best wishes to you, and I sincerely hope you will not let your fears (and the scare tactics of the providers) keep you from enjoying this pregnancy and this baby.  Be as healthy as you can in your habits without obsessing over them, find a Pregnancy Buddy or Size-Friendly Doula to help you speak up for yourself, and don't be afraid to push back against the bias of your providers and even report them to their superiors if necessary.

Pregnancy is one of the best times to learn how to advocate for yourself, your baby, and your needs (whatever size you are), and you deserve to have loving, respectful care, regardless of your BMI or whether you lose enough weight to fit into their narrow definition of "normal".  Start demanding that care now, and don't settle for second-best.  You and your baby deserve no less.


*Please keep your comments civil and kind and aimed towards helping this woman's specific situation or about commenting on weight-biased scare tactics, rather than about pushing a particular point of view on abortion. This is not a forum for abortion debates, and I will be vetting comments before I publish them.  Please stay kind and helpful in your words.  Thank you.

Fetal Over-testing in the Last Trimester Because of Fat?

This is a comment that was left on my blog recently, in the "Will I Feel My Baby Move If I'm Fat?" post. It's a new twist on the old wives' tale (more like old OB's tale) that fat women supposedly have too much abdominal fat to feel their babies move in pregnancy.

"I am 29 weeks today and a nurse practitioner I saw last week told me I have to have nonstress tests 2X week because of my weight. She claims I won't feel the baby's movements so they need to monitor them. Has anyone else been told this? I'm a very busy woman and incredibly stressed about having to go to the hospital 2X week, plus she says I have to do an ultrasound monthly, plus do my weekly doctors appts. Advice would be great because I don't want to do this but I feel I have to so the baby will be monitored appropriately."

Seriously?  A non-stress test 2x per week from 29 weeks on because a fat woman supposedly won't feel her baby's movements? 

This is pure and unadulterated bullsh*t.  Women of size feel their babies move perfectly well, thank you. There's no fat between the baby and the inside of the uterus; we feel every roll and punch and kick.

Nearly every woman of size I've ever spoken to has said that yes, they feel their babies move just fine; I certainly did. Yet this myth about fat "preventing" women from feeling their babies still persists. That it persists among the public is disappointing but attributable to ignorance; that it persists among some healthcare providers is nothing short of appalling.

But the second question here is whether fat women are so incredibly high-risk from "obesity" alone that we have to be monitored 2x/week from the middle of the second trimester on?  Yet other women only start monitoring around week 41? Oh puleeeze.

Even most diabetics aren't monitored this aggressively. Insulin-dependent diabetics usually start fetal surveillance around 32 weeks. For gestational diabetics not on insulin, the need for fetal surveillance is widely debated; if used at all, it is usually introduced around the end of pregnancy.  Only diabetics with severe comorbid complications like vascular issues or kidney disease usually benefit from this kind of aggressive monitoring starting in the late second trimester. Are the providers in the above scenario seriously comparing the risk of an uncomplicated pregnancy in an obese woman to that of a brittle type 1 insulin-dependent diabetic with pre-existing kidney damage?

The only time I can see this kind of over-the-top monitoring being truly needed in a woman of size would be in someone who has experienced serious major poor outcomes in a previous pregnancy, or who is experiencing major complications in a current pregnancy (HELLP syndrome, hypertensive disorders, prior stillbirth, brittle or uncontrolled diabetes, diabetes with comorbidities, IUGR, or various other serious complications). The commenter didn't mention any such comorbidities.

Now, the argument some docs make for increased fetal surveillance in "obese" women is that some studies have shown an increase in the risk for stillbirth in these women.  However, not all studies have shown an increase in the risk of stillbirth in obese women. Moreover, there is no data to prove that aggressive monitoring in obese women lowers the risk for stillbirth.  

It is questionable whether obesity itself, without concurrent complications like HELLP or uncontrolled diabetes, necessitates this kind of frequent monitoring.  It is telling that most care providers do not require it. The American College of Obstetricians and Gynecologists (ACOG) does not currently recommend increased antepartum surveillance in the last trimester for obese women.  Nor does the Society of Obstetricians and Gynaecologists of Canada (SOGC).  And research suggests that obese women don't have more poor results on non-stress tests.

Although there may be a somewhat higher risk for stillbirth in women of size, and although non-stress tests and biophysical profiles can sometimes help identify babies at high risk for stillbirth, these tests don't always help and come with downsides too. The rate of  false-positives is quite high, and often results in unnecessary interventions like early induction of labor or cesareans, and these also carry risks.

So while I can understand some providers wanting to offer this as an option to women of size (especially those who experience comorbid complications like hypertension disorders or restricted growth), I strongly question the value of its routine use in women of size with uncomplicated pregnancies. Furthermore, the testing schedule this woman has been put on is quite excessive (barring some complication we are not aware of).

Awareness of the possibility of complications in women of size is one thing, but clinicians must remember that over-testing brings its own risks and often becomes a self-fulfilling prophecy.

I've been through four pregnancies as a "morbidly obese" woman and I was never required to do this kind of monitoring. Nor do I know many other fat women who have been required to do this extreme amount of monitoring. And I can assure you that I most definitely felt my baby well enough to do kick counts by the end of pregnancy.  The idea that non-stress tests or biophysical profiles are required because fat women are too fat to adequately keep track of their baby's movements is ludicrous.

Commenter, unless you have some major complication we don't know about, you might want to think about running far and fast from this practice so you can find one that doesn't see you as such a ticking time bomb.  Pick a practice that knows that fetal surveillance testing has both pros and cons, that knows there is a high risk of false positives and over-intervention with these tests, and that is willing to discuss these pros and cons with you and let you make the final decision on their use instead of compelling you to follow an arbitrary schedule of testing virtually designed to find problems and intervene.

*How about you?  If you are a woman of size, have you been required to have such aggressive fetal surveillance from so early on?  What kind of fetal testing was recommended for you as a woman of size by your providers?

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

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

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

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

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

There was yet another blood pressure-raising example of this from My OB Said What?!? recently, where one OB said to a "morbidly obese" mother:

I can't believe I have been put in this position!  I absolutely resent that I am now responsible for your life and delivering this baby, you have no right thinking you can safely deliver a child when you are so overweight.    

In the comments section on the My OB Said What?!? website, the original poster gave some more details behind the case. The mother weighed in the upper 200s in her pregnancy and had had a healthy pregnancy.  At one week overdue, she had a slow leak of her amniotic fluid (normally not a big deal, but in this case it had leaked out enough that contractions were pressing on the baby's umbilical cord and interfering with his heart rate).  They took her back for a cesarean, where the on-call OB began to berate the patient and her husband with the above statement ─ and more:

This was the LEAST of the horrible things he said to my husband and I.  He lectured my husband so severely that my big tough husband started to cry.  He told us that I and the baby were about 85% likely to die on the table during the surgery and it was all hubby's fault because I am SO fat. 

What the hell.....??!!!  Where does this doctor get off treating a patient, ANY patient, no matter her risk factors, like this?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Because Of Your Weight, We'll Schedule Your Cesarean

Still find it hard to believe that fat women are being denied access to low-intervention care and are often railroaded into cesareans these days?

Try this story on for size, from the website, My OB Said What?!?

“Because Of Your Weight…We’re Going To …Schedule Your Cesarean.”

“Because of your weight, you’re just not a candidate for midwifery care, and we’re going to go ahead and get you to an OB to schedule your cesarean section.” – CNM to mother at 36 week appointment

Augh.  Just AUGHHHHH!!!  On sooooooo many levels.

Anesthesia and Wound Complications in Cesareans in "Morbidly Obese" Women

This month is Cesarean Awareness Month.  We are continuing our month-long focus on the overutilization of cesareans in the USA as a whole, and in particular in the subgroup of "obese" and "morbidly obese" women. 

In the United States and many other countries, many care providers are unfortunately moving towards a policy that a planned "elective" cesarean is the delivery method of choice for "morbidly obese" women.  As we recently discussed, they assume that very fat women are unlikely to birth vaginally anyhow, that vaginal birth in very fat women is unsafe for the baby, that an emergent cesarean would take too long to save the baby, and that just doing a planned cesarean ahead of time as a matter of routine care will result in better outcomes among these women.

However,  as we pointed out, a recent study from the U.K. shows that in fact, routine planned cesareans do not improve outcomes at all (and there was a trend towards poorer outcomes in the planned cesarean group).  Furthermore, the study found that 70% of the women with "extreme obesity" (defined as BMI of 50 or more) were able to give birth vaginally when they were given the chance to. 

Now, two other studies confirm that the policy of routine planned cesareans in "morbidly obese" women carries significant risks for these women. In the first study, high rates of anesthesia complications were found in planned cesareans for "morbidly obese" women.  In the second study, even higher rates of wound complications were found as well. 

Increased Anesthesia Complications

It is well-known that people of size are at higher risk for anesthesia complications. General anesthesia is far more risky in "obese" people, and difficult intubations account for some rare but very serious complications that are sometimes seen in general anesthesia in "obese" people. 

This is why regional anesthesia (epidural or spinal) is the anesthesia of choice for cesareans in women of size.  However, even with regional anesthesia in women of size, there is a higher rate of difficult placements, inadequate anesthesia, anesthesia that wears off too soon, or low blood pressure during the surgery.

In the first study (Vricella 2010), about 1 in 12 "morbidly obese" women who underwent a planned cesarean with regional anesthesia experienced a significant anesthesia complication.

No, the complications were not because they were trying to do a difficult epidural or spinal placement on an "obese" woman during labor.  These were planned cesareans.....not emergency cesareans, but cesareans planned ahead of time, with regional anesthesia. 

And still, 1 in 12 had anesthesia complications.

High Rate of Wound Complications

In another study from around the same time (Alanis 2010), researchers looked at the complications associated with cesareans in women with "massive obesity" (BMI of 50 or more). 

They found a much higher rate of wound complications than they expected.....30%, or about 1 in 3. 

Now the reasons for this higher rate of wound complications are many (and there's another blog post on this coming soon), but even so, about 1 in 3 is a really high rate. 

Their focus?  Changing the management that increases the risk for wound complications, such as subcutaneous wound drains and vertical incisions.  And these are very valid points....again something we'll be blogging about soon.....but the bottom line should have been making every effort to reduce the number of cesareans being done in this group at all.

Summary

These new studies present yet more compelling reasons to avoid unnecessary cesareans in women with "morbid obesity." 

Yet currently, many providers in the USA automatically schedule "morbidly obese" women for planned cesareans as a routine procedure, claiming it to be safer for the mother and baby, despite research showing that this is not true.

This practice has to change.

Most very fat women CAN give birth vaginally if just given an adequate chance to.  Automatically scheduling them for planned cesareans instead exposes the entire group to high rates of anesthesia complications, wound infections, blood clots, and hemorrhage, not to mention increased complications in future pregnancies. 

It is indefensible to place an entire group so at risk like this, across the board.

It is time for doctors to recognize that they are causing MORE harm than good through the practice of routine planned cesareans in "morbidly obese" women. 



References

Vricella LK, Louis JM, Mercer BM, Bolden N.  Anesthesia complications during scheduled cesarean delivery for morbidly obese women.  Am J Obstet Gynecol. 2010 Sep;203(3):276.e1-5. Epub 2010 Jul 31. PMID: 20673866

OBJECTIVE: We sought to estimate the morbidity associated with regional anesthesia in morbidly obese women undergoing scheduled cesarean delivery. STUDY DESIGN: This was a retrospective cohort study of women undergoing elective scheduled cesarean delivery from September 2004 through December 2008. RESULTS: A total of 142 morbidly obese, 251 overweight and obese, and 185 normal-weight women met inclusion criteria. Differences between groups were identified regarding: complicated placement (5.6%, 2.8%, and 0%, respectively; P = .007), failure to establish (2%, 0%, and 0%, respectively; P = .047), and insufficient duration (4%, 0%, and 0%, respectively; P = .02) of regional anesthesia. The groups differed in the frequency of general anesthesia (6%, 0%, and 0%, respectively; P = .003), intraoperative hypotension (3%, 0%, and 0%, respectively; P = .01), and overall anesthetic complications (8.4%, 0%, and 0%, respectively; P less than .0001). Prepregnancy body mass index greater than or = 40 kg/m(2) (receiver operating characteristic area under the curve, 0.856; positive likelihood ratio, 4.0) and delivery body mass index greater than or = 45 kg/m(2) (receiver operating characteristic area under the curve, 0.877; positive likelihood ratio, 4.1) were predictive of anesthetic complications. CONCLUSION: Morbidly obese women have significant risk for anesthesia complications during cesarean delivery.

*My snarky reply to their conclusion: So stop doing so many cesareans already!

Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ. Complications of cesarean delivery in the massively obese parturient.  Am J Obstet Gynecol. 2010 Jul 31. PMID: 20678746

OBJECTIVE: The objective of the study was to determine predictors of cesarean delivery morbidity associated with massive obesity. STUDY DESIGN: This was an institutional review board-approved retrospective study of massively obese women (body mass index, greater than/=50 kg/m(2)) undergoing cesarean delivery. Bivariable and multivariable analyses were used to assess the strength of association between wound complication and various predictors. RESULTS: Fifty-eight of 194 patients (30%) had a wound complication. Most (90%) were wound disruptions, and 86% were diagnosed after hospital discharge (median postoperative day, 8.5; interquartile range, 6-12). Subcutaneous drains and smoking, but not labor or ruptured membranes, were independently associated with wound complication after controlling for various confounders. Vertical abdominal incisions were associated with increased operative time, blood loss, and vertical hysterotomy. CONCLUSION: Women with a BMI 50 kg/m(2) or greater have a much greater risk for cesarean wound complications than previously reported. Avoidance of subcutaneous drains and increased use of transverse abdominal wall incisions should be considered in massively obese parturients to reduce operative morbidity.

*Illustration credit: Amy Swagman of The Mandala Journey.  Used with permission. Isn't it amazing?

Too Out Of Shape For Birth?

Here's another little gem from the blog, My OB Said What?.  It covers the common misperception among obstetric caregivers that fat women are too "out of shape" to give birth vaginally and/or naturally. 

“You are quite overweight and you need to be healthy to naturally birth a baby. You wouldn’t make it because you would get puffed out and tired.”

-OB to overweight mom who wanted a natural birth

This is a very common belief among many people, both lay and medical.  The idea is that you have to be in great athletic shape in order to give birth naturally. 

There are two problems with this. 

First is the common assumption that "overweight" and "obese" women never get any exercise and therefore this mother couldn't possibly be in decent shape. (The corollary, of course, is that all average-sized women obviously do get exercise and are always more fit than fat folk.)  Neither is true.

Second is the assumption that you have to be fit in order to give birth naturally, that labor and birth is like running a marathon and only the most fit and tough can do it naturally.  Baloney.  Fitness helps, but it's no guarantee either way.

Assumption: "Obese" Women Never Exercise And Aren't In Shape

Many doctors and laypeople assume that fat people never exercise and can't possibly be in decent shape.

This is nonsense.  Many fat women do exercise and of course, many skinny ones do not.  You can't tell by looking at body size who gets exercise and who does not. 

It goes back to that common societal belief that if you are fat, it must be because you don't eat well and don't exercise at all.  Anyone who made any real effort at it would obviously be "normal-sized" or pretty darn close to it.  Therefore, in that mode of thinking, all fat people are, by definition, not fit.

I would agree that it's possible that fat people, on average, may be less fit than average-sized people....certainly fatness can be more physically challenging in some ways (especially as we age), there are many barriers to exercise for people of size, and some fat people really are sedentary....but you just cannot make assumptions about individuals based on size.  I know "overweight" and "obese" people who run, bike, and hike regularly and are very fit.  I also know ones who are not.  But you can't really tell by looking.

This doctor should not be making assumptions about fitness level based simply on the mother's size.

Assumption: Only The Most Fit Can Birth Naturally

Although I think it's true that it helps to be reasonably fit for pregnancy and birth, it's certainly not a requirement for normal vaginal birth.  The uterus is a muscle and works independently of the fitness of the rest of the person. 

I mean, for heaven's sake, there have been cases on record where paralyzed women have given birth vaginally.  If a person who cannot actively help push out her baby can birth vaginally, then obviously fitness is not an absolute pre-requisite for giving birth vaginally. The uterus can do it on its own, if the baby is well-positioned.

That said, pregnancy is wearing on the body and labor is certainly not a walk in the park.  I do think that folks who get regular exercise in pregnancy tend to have fewer complications in pregnancy (less gestational diabetes and perhaps less pre-eclampsia), and it may help them have an easier birth.  It also helps to have some endurance on board if the labor is hard or long. 

However, fitness and athleticism are not an absolute requirement for having a vaginal birth or a med-free childbirth.  I know plenty of very fit, very athletic women who have had cesareans, and plenty of not-very-fit women who have had vaginal births (and natural, unmedicated vaginal births at that). 

My Experience

In my own life, I exercised quite a bit in pregnancies #2 and #3, but because of coincidental life issues, not as much with #1 and #4.  (I was "morbidly obese" and of similar weight with each, so that was not a relevant variable on its own.)

I had very little exercise and a cesarean with the first, exercised a lot with #2 but still had a cesarean, exercised a lot with #3 but had a vaginal birth, and exercised not-a-lot with #4 and still had a vaginal birth (a completely natural, unmedicated birth in the water to boot). 

I did notice a difference in how I tolerated pregnancy; I definitely was most comfortable in the pregnancies in which I exercised regularly.  So I'm a big fan of promoting exercise for pregnant women of all sizes.  But not getting as much exercise in my last pregnancy didn't prevent me from having a vaginal birth. 

I absolutely encourage women (and especially women of size) to exercise regularly in pregnancy because it really does help you feel better, lowers your risk for complications, may help you during labor, and will help your body recover faster afterwards.

But do you have to be skinny or an athlete to have a vaginal birth?  Of course not.  Just read the comments on the My OB Said What? page.  Many were from fat women who birthed vaginally and all naturally just fine, with or without regular exercise.  And I have birth stories on my website from fat women, even supersized women, who have had natural vaginal births without problems.

Yes, fat women have more cesareans.  But is that really only because of their fatness, or because of a combination of more complications, an extremely high rate of induction in fat women, the extremely interventive way that fat women's labors are managed, a higher rate of malpositions, and a very low threshold for surgery for fat patients among their OBs?

Conclusion

Focusing on fitness/exercise as a requirement for natural birth is just another argument that doctors (and sometimes midwives, alas) use to convince fat women that they:

• will "need" a cesarean
• couldn't possibly push out a baby because they are too unfit or too fat
• couldn't possibly push out a baby without help from forceps or vacuum extractor because they aren't strong enough to push hard enough
• are too weak to endure labor without drugs
• won't produce strong-enough contractions on their own and will definitely "need" pitocin
• couldn't possibly have a vaginal birth without losing tons of weight or taking up marathons beforehand

(Yeah, those are all real things that have been told to women of size.)

Let's be clear. Fat women can and often do exercise.  Just because you are fat doesn't mean you don't exercise.  Could many fat women exercise more?  You betcha.  Could many average-sized women exercise more?  Yes. You simply cannot make assumptions about exercise habits and fitness based on a person's size.

Second, exercise and fitness is NOT necessarily a pre-requisite for birthing vaginally.  It definitely helps, and women should definitely be encouraged to be active in pregnancy....but the story is much more complex than that.  There are far more factors than fitness and athleticism at work in birth.

So is fitness an absolute requirement for birthing vaginally or without medications? Heck no.

And can fat women, fit or unfit, birth vaginally? Hell yes.

You will probably just die anyway

The things some doctors tell women of size about pregnancy are just appalling. 

Scaring fat women about dying in pregnancy seems to be the latest scare tactic to keep fat women from even contemplating reproducing.

Here's yet another example from My OB Said What??!!

“If you get pregnant, you will get gestational diabetes, have high blood pressure, and oh, you will probably just die anyway.”


-Gynecologist to a young, obese woman who was not pregnant at the time of the gyn exam

It's amazing how all this fatness keeps getting passed down over the generations since all us fat moms die during pregnancy, you know? 

What kind of ridiculous things have you had said to you about pregnancy at larger sizes?

Will I Feel My Baby Move If I'm Fat?

Whether or not a fat pregnant woman will feel her baby move is one of those myths about fat women and pregnancy that you hear periodically.

I don't hear it very often, but I have heard it a number of times over the years. 

It never ceases to amaze and surprise me that some non-fat folks actually believe this nonsense, but they do.  Some people actually tell fat women that they will never feel their baby move or kick because of their fatness. 

Puleeeeeeeze.  Like there is fat inside your uterus that will prevent contact between your baby and the uterine wall?  Like the nerves in the area don't function in the presence of adipose tissue?  Like there is soooo much fat in the abdomen that nobody from the outside could possibly be able to feel an 8 lb. bowling ball rolling around inside?  Come on!!

Plus, there's the actual experience of fat women.  We feel our babies move, trust me.  But somehow, either that experience doesn't get communicated to non-fat folks or they just don't believe it.

So you get these people who tell women that they probably won't feel their babies move in pregnancy because of their fatness, or that their partner will probably never feel the baby move either.

Personally, I think it's another way to make fat women feel bad about pregnancy, like they can't experience all the normal pregnancy stuff other women get to have.  People may not consciously be trying to shame or make fat women feel bad with these remarks, but deep down I think that the unconscious motivation is tsk-tsking.  Really, anyone with half a brain who took a second to think about it (or ask a fat woman about their experience) would know it's not true.

It's like saying, Yeah you can have a baby, but you are so fat you won't get any of the pleasure that goes with it.  Nyah, nyah.

People may not always intend it in a mean-spirited way--it may simply come from ignorance--but what a joy-killer a remark like this is.  Shame on the people who perpetuate this kind of nonsense. 

One Woman's Story

Here's an email I got a while back from someone with exactly that question, plus my reply to her. 

Someone told my husband that I may not be able to feel the baby kick or move because of my weight. I was searching your site...and was just wondering if this is true. It doesn't sound right to me ... because the baby is inside my body...

My Reply:

You are correct. You will feel this baby move. There is no fat inside the uterus, so you will feel the baby move inside you just fine.

You'll probably feel it on a similar timeline as a woman of average size, which can be anywhere from the 12th week or so till the 26th week or so. In fact, you probably are already feeling the baby move but if you've never been pregnant before, you simply may not recognize it as fetal movement yet. It's really very subtle at first. And it takes a while to be sure you really know what it is.

From the OUTSIDE it's true that it may be harder to feel the baby move early on because of intervening "fluff," but in time it will also be felt there. It may happen later than it would happen in a person of average size, but sooner or later, your partner (and you) will be able to feel this baby move from the outside too.

The one caveat to this is that if you have an anterior placenta (a placenta that has implanted on the front side of your uterus, near your belly), that can make it harder (and take a little longer) to feel the baby move internally and/or externally.  It definitely makes it harder to find the baby's heartbeat at first, as I know from my own experience with one of my kids.  But that has nothing to do with obesity, just with placental placement. Skinny women with anterior placentas have the same problems.

Rest assured, you will eventually feel the baby move from both the inside and the outside. You'll feel it from the inside on a similar schedule as other women; it may take longer to feel from the outside, but it will happen.

I'm "morbidly obese," have had 4 babies now, and have been able to feel all of them move, both inside and out. Sometimes I felt the baby moving in the first trimester, usually it was early to middle second trimester, and with my third it was late in the second trimester (because I had an anterior placenta).  But I felt them every time, and eventually so did my husband.  There was never any problem with it.

Even the most supersized woman I've encountered has felt her baby move, sooner or later.

So don't worry, you won't miss out on this wonderful feeling! Feeling your baby move is one of the most special things about pregnancy, so enjoy the heck out of it once you do feel it. It's one of the things I miss most, now that my childbearing days are done. 

Treasure it forever, and don't let some ignorant stranger worry you about it.  In this way, as in so many other ways, your experience of pregnancy as a woman of size will be very comparable to that of other women.  Your weight won't keep you from feeling your baby move, don't worry.

*Anybody out there ever hear this chestnut?