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.

Check Out My New Post at Science and Sensibility!

On the childbirth blog, Science and Sensibility, there is currently an ongoing series about "obesity" and pregnancy.  All the usual material is there, be warned, but to its credit, it has also solicited the views of women of size, something most of these discussions never do.

So I submitted some posts on the topic and my first one is up on the blog today.  Huzzah!

Go forth and read it, link to it, "like" it, tweet it, digg it, and whatever else you can do to increase its visibility and readership. Give it some serious love, people.  Having an alternate point of view represented is a major step forward.

I do have one request, though; if you comment on my post or anyone else's, be respectful and polite as you make your points.  It's a radical thing to have our voice actually represented in these discussions and we want that voice heard and taken seriously.

There will be further follow-up posts from me there, so stay tuned to the Science and Sensibility blog for more!

A Note About Terminology

I'd also warn FA activists that I use the "o" words in the post at times.  While I strongly dislike these terms, I've found over the years that the medical establishment doesn't take you seriously if you only use alternate terms, and the word "fat" is seriously alienating to a lot of women who aren't on board with the fat-acceptance thing yet. 

Also, it's a search-engine optimization thing; the fact is that most of the terms used to search out this blog and my website involve "overweight" or "obesity" or variations thereof.  Back in the days when I scrupulously avoided these like a good NAAFA-ite, it really limited who would find my information. Often it kept the people who MOST needed to hear it (newly pregnant fat women, those facing fat-phobic treatment and misinformation, or care providers looking for information about weight and pregnancy) from finding it altogether.

So I grit my teeth and use the "o" words at times, both here and when I write about the topic elsewhere.  Here I use scare quotes around "obese" etc. to show that I GET it and I don't like those terms either.  Elsewhere I don't always, for style reasons and to be taken more seriously by medicos. But it doesn't mean that I don't agree with the objections to these words. 

In making this compromise, I am taking my cue from various researchers and authors who write about HAES topics and have also had to negotiate a compromise between ideals and practicality.  Here's a summary from Saguy and Gruys, in their article on the way that the news media frames articles on obesity vs. eating disorders (an awesome article, BTW, if you've never read it):

The definition of “overweight” and “obesity,” and even these terms themselves, are contested. Fat acceptance activists, who advocate for civil rights on the basis of body size, argue that these terms pathologize normal biological variation and reclaim the word “fat” as a neutral descriptor like “tall” or “short” (Cooper 1998; Wann 1999). Similarly, many feminist scholars have avoided the term “eating disorder” because it situates “disorder” within individuals rather than in complex social structures. We do not use “overweight,” “obesity,” or “eating disorders” because we endorse a medical or public health framing, but because we seek to establish how these particular terms have been constructed in the news media. We note that a search for articles using the term “fat” produced very few relevant articles, which is not surprising given that this word is still taboo in most social circles in the contemporary United States. An article search using the term “eating problems” was similarly unproductive. For stylistic reasons we do not place the terms “overweight,” “obesity,” or “eating disorder” in quotations throughout the article, but we wish to be clear that this is the spirit in which we use them.

So hopefully that will explain why I use these terms at times, even as I hold my nose. 

The best compromise I've found so far is to mix up my use of terms, using the "o" words mostly when discussing medical research, using "fat" as a descriptor of size or when talking about FA things, and using terms that are seen as more neutral (like "women of size") as much as possible in between.

You can agree or disagree with that compromise, just remember that I've done it for practicality reasons only. 

Ties Into Upcoming Series

This series of posts on Science and Sensibility ties well into my upcoming series on this blog on the risks of "obesity" and pregnancy, one I've been working on for a long time but have had trouble finishing because it's so research-intensive and I've been so busy. 

For that reason, it will be a periodic series.  We'll do an overview first, then take one risk at a time and dissect the research on it, and finish by overviewing what might be done to help lessen the risk for that complication. 

As I said, it will be a periodic series; other posts on other topics will get interspersed between to allow me time to work on each installment.  I'm sure it will take me a long time to finish the whole series, but bit by bit we'll get there.

This can be a difficult subject to discuss, because the last thing I want to do is scare pregnant women or those considering whether or not to have a baby. And information about risks can certainly scare anyone considering pregnancy.  But it's also a disservice to pretend there aren't any risks, or to not discuss ways in which women of size can be proactive about risks.  To me, knowledge is power, and this is an important discussion to have.  Just keep it in perspective.

Remember that risk discussion, by its very nature, tends to inflate people's perception of risk.  Add in pregnancy, when women feel most vulnerable, and risk discussions can be a bit scary. They narrowly focus on the small minority of people who have complications, rather than the large majority of those who do not.

Just keep reminding yourself that most of the time, pregnancy goes perfectly well, and many MANY women of size have had healthy pregnancies, healthy babies, and healthy births. 

Participatory Medicine and Why You Should Know About It

Amy Romano, CNM, posted a while ago on her blog about the "new" concept of Participatory Medicine, and recently commented on it again.

I've been ruminating on this topic for quite a while now but just never got around to finding the links I needed to finish the original post. 

I think the topic still bears commenting on, even if it's not a very timely response to her original post.  This is what I originally wrote, adapted and re-edited recently. 

Participatory Medicine is a new paradigm in healthcare that has particularly resonant implications for childbearing women and for people of size. 

Here's the definition of Participatory Medicine from the e-patients website:

"Participatory medicine is a cooperative model of healthcare that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. The 'participatory' concept may also be applied to fitness, nutrition, mental health, end-of-life care, and all issues broadly related to an individual's health. The Society was founded to learn about and promote Participatory Medicine through writing, speaking, social networking, and other channels."

Participatory Medicine is really nothing new to us in the birth activism movement, nor is it really anything revolutionary to those of us in the Health At Every Size (HAES) movement. Both have been advocating patient collaboration in their own care for many years.

But even so, this movement formalizes what we've been saying for years and is definitely something we should be paying attention to.

Those of us who have had children know how often we have faced condescension from caregivers about the idea that we could become knowledgeable about and have a say in our own children's births, and those of us who have tried have frequently faced a great deal of resistance.

And those of us who are people of size know how often we have searched for a provider who could see beyond our weight and into our individual circumstances, who understood the starkly unlikely chance of permanent weight loss, and who was willing to shift their care paradigm from a weight-centered model to a health-centered model instead.

Participatory Medicine and Birth

Here's a link to Amy's post to the Participatory Medicine site, proposing that maternity care is the perfect place to start as an "e-patient":

http://e-patients.net/archives/2009/09/a-lifetime-of-participatory-medicine-can-start-with-maternity.html

Basically, it's what many of us in the birth movement have been encouraging for years....empowering patients to do their own research, question their healthcare practitioners, look into alternatives, find a new provider if needed, make decisions in partnership with healthcare providers, and take responsibility for their healthcare decisions. Only now it has an official "name" and a whole movement behind it.

Of course, some doctors are threatened by the Participatory Medicine model. In particular, obstetrics providers seem to be extremely threatened by it, partly because of the vulnerability to litigation they feel in this field, and partly because of the high level of paternalism and misogyny in the field (even from women physicians). 

Participatory Medicine has been going on in the cancer field for years (see the story of Intel's Andy Groves' experience with prostate cancer years ago) and is fairly accepted there now......and frankly, I observe that many of the voices I see in the Participatory Medicine groups are from the cancer field.

Interesting that Participatory Medicine is SO very resisted in the maternity care field when it's relatively accepted in the cancer field.

Even the same OB-GYN who is open to working in partnership with a woman on decision-making if gynecological cancers occur, often did not give that woman any meaningful say in her choices when she was giving birth.

This is part of the paternalistic view of birth, one that now sees the baby as the primary patient and the mother's needs as endangering the safety of the baby; one that sees the mother as a hysterical, overly-emotional person who is not competent to make her own decisions near the end of pregnancy or while in labor.  [Yes, there are doctors that argue this.]

In this worldview, the mother is the enemy, the culprit and scapegoat if anything goes wrong.  The caregiver is seen as needing to save the baby from the mother's "hostile" uterus, selfish personal habits, or narcissistic desires for a "good" birth.

When a caregiver views mothers as the main source of harm to the real patients (the babies), is that caregiver going to see that source of potential harm as a real partner in decision-making? Or the main obstruction in the way of "saving" the baby?

Another barrier to Participatory Medicine in obstetrics is the cultural training for patients to turn over all personal responsibility for medical choices to their physicians.  This is particularly prevalent in obstetrics, where the woman gives all the power for decision-making to the doctor because of the doctor's extensive training in the field, thinking, "Who am I to disagree with such an expert if he says I have to do this for the baby's sake?"

Obviously, doctors do have a great deal more training and expertise in these medical issues than most patients do and their opinions must be considered carefully, but just ceding over all decision-making powers ignores the fact that doctors disagree with each other all the time about the best course of action. 

Go to one doctor, and you'll likely get one recommendation about what you should do.  Go to another, and you'll likely get different advice.  Go to enough doctors, and you'll probably get totally conflicting advice about what your best course of action is.....in cancer, in heart disease, in chronic illness, even in pregnancy.  Most patients don't recognize just how much medical advice can vary from one care provider to another because they never bother to get a second or third (or more) opinion.

Either you are blindly willing to trust your health and your baby's health to whichever doctor you randomly picked first by praying that you picked well, or you are going to have to do some research and make some decisions based on your values, knowledge, and priorities.....even if that means getting second opinions, exploring alternatives, or seeking out a different care provider who is more in alignment with your priorities.

Some pregnant women don't want any responsibility for these difficult choices, so they cede all decision-making to their doctors.  Such compliant patients are very convenient for obstetricians.........until it bites the doctors back when something goes wrong and the patient sues.

What most maternity field providers don't yet see is that Participatory Medicine benefits doctors too. When parents are involved in active decision-making.....when they really understand all the benefits and risks of a particular choice.....they take on more responsibility for these choices and are less likely to blame the doctor and sue if something goes wrong.  We see this in midwifery care, and we would probably see this in obstetrics too --- if more doctors were willing to practice that way.

Maternity care is the perfect field for Participatory Medicine, but it is probably one of the least participatory of all fields of medicine. Fortunately, caregivers who follow the physiological/midwifery model of birth (regardless of actual job title) do usually practice Participatory Medicine, and this is placing pressure on the medical model like never before to start opening up the decision-making process. 

But as always, it is the consumers who will lead the way in pushing for the participatory model.  Vote with your feet and with your pocketbook.  Choose a maternity care provider who, while providing valuable expertise and perspective, actively shares the decision-making with you and respect the choices that you make.

Participatory Medicine and Health At Every Size

The Participatory Medicine movement also has great implications for the HAES (Health At Every Size) paradigm and people of size.  It also has major implications for the "Bariatric" and Endocrinology fields, if they were only open to seeing it.

Those of us who have really looked at the research know that the rate of long-term success in weight loss is extremely low, and often, weight fluctuations do more harm than good. If the long-term results are examined, many folks end up weighing more in the long run than they did at the start of a diet, and a repeated pattern of dieting is often a major source of increasing obesity and disordered eating.

In what other field would medical experts keep recommending a treatment that has such a low degree of long-term success and a strong chance of making the patient worse off than when he/she started?

Would such poor results be promoted or even tolerated in the cancer community?

Many people of size have long taken charge of their own medical care by opting out of the radical weight loss paradigm, and instead choosing a health-based model over a weight-based model.  This dovetails nicely with the HAES approach of reasonable nutritional and exercise habits for improving or maintaining health, independent of weight.

Many of us refuse to buy into the common medical-paradigm idea that weight loss is always a good idea and is always helpful, and that any means used to achieve it is worthwhile, no matter how radical.

Many of us know from painful experience that the dieting and weight cycling often does more harm than good. Many of us know that we are healthier, mentally and physically, when we do not actively try to lose weight but rather choose to emphasize reasonable nutrition and exercise instead. Many of us ascribe to the radical idea that emphasizing reasonable, healthy habits will improve our health far more than trying to reach some unrealistic and arbitrary weight goal.

Alas, despite research backing up the HAES model, this is a difficult sell to those in the Bariatric and Endocrinology fields, whose training is usually laced with deeply fat-phobic biases against people of size.  Most are trained to think of obesity as the cause of most evils, as weight loss as the only "cure," and to make many assumptions about how fat people "must" be eating and living in order to be fat. 

To share decision-making with patients means actually listening to and believing them about their condition and habits, and this contradicts everything most of these healthcare professionals have usually been taught to believe about fatness.  Thus, those in the Bariatric and Endocrinology fields are unlikely to buy into HAES and Participatory Medicine anytime soon.  It requires too much change to their worldview about fatness.

Alas, the HAES model may also be a difficult sell to some of those already in the Participatory Medicine movement. 

Some Participatory Medicine advocates may have bought into the "magical thinking" mindset that if they can only improve their diet enough, lose enough weight, get enough exercise, etc. that the cancer (or whatever) will not return or would never have occurred in the first place. 

Others have been listening to the mainstream media distortions about the "obesity epidemic" and will find it difficult to consider the seemingly counter-intuitive idea that dieting may actually worsen health in some cases and that not losing weight may actually be a better choice for some people. 

Therefore, the idea of questioning the efficacy and benefits of weight loss may be particularly difficult to some in the Particpatory Medicine movement.

I'm sure many Participatory Medicine followers believe that weight loss is the right way to go for their own health.  And of course, if that's the choice that they want to pursue, they have every right to do so.

But the good thing about Participatory Medicine is that it pushes people to look at things from a more evidence-based point of view.  Hopefully they will read the research and see just how poor the odds for long-term weight loss are among chronic dieters, how it may increase the risk of certain problems, and recognize that as with many other diseases, sometimes the "cure" may be worse than the "disease."

More than that, hopefully the folks embedded in the e-patient movement will remember the principle of self-determination that is so important in the concept of Participatory Medicine --- that pursuing weight loss or not is a choice we deserve to make for ourselves, not have forced upon us as a requirement for care (mandatory weight reduction before organ transplants or surgery, for example).

In the end, we should get to decide whether or not a prescribed course of treatment is right for us or not, we should get to decide whether another round on the diet merry-go-round is going to be helpful or harmful for our individual situation, and we should get to decide whether or not to pursue alternative paradigms of care (like Health At Every Size). 

And that's the heart of Participatory Medicine, isn't it?  People taking the evidence, making decisions in partnership with their care providers, and taking responsibility for them.

Conclusion

Really, there is a great case to be made that Participatory Medicine is one of those innovations that is going to change medicine as we know it.....it's a model rapidly taking over, and protesting it is trying to shut the barn door after the horse is already out. It's coming whether doctors want it or not, and they might as well get on board and embrace the positive facets it brings to patient care.

Participatory Medicine has been quick to catch on in cancer and related fields, but has been slow to be adopted in Childbirth, "Bariatric" and Endocrinology fields.  In fact, in these fields, it is often actively resisted on the basis of condescending and paternalistic attitudes that women giving birth and fat people cannot be trusted to make these kinds of major life decisions, that they are too compromised by their own conditions to see the choices objectively.

But the barn door is open, the horse is galloping off, and Participatory Medicine is rapidly taking over.  Its influence is even being felt in the highly-resistant field of Childbirth; it is only a matter of time until it is heard more in the even-more-resistant fields of Bariatrics and Endocrinology. 

Here is a link to the Seven Preliminary Conclusions of Participatory Medicine:

http://e-patients.net/archives/2009/01/the-e-patient-white-paper-seven-preliminary-conclusions.html

Here are a couple more links to an opinion piece from a doctor called "Doctors Are Killing Their Profession, The Healthcare System, and Their Patients with Paternalism."

http://e-patients.net/archives/2009/10/doctors-are-killing-their-profession-the-healthcare-system-and-their-patients-with-paternalism.html

http://www.docpatientblog.com/2009/09/doctors-are-killing-their-profession.html

Personally, I think this is pretty important stuff, and something that has the power to really transform the practice of medicine.

Please, go check out the e-patient website. And whether you are a birthing person, a person of size, a cancer patient, or whatever.........start making yourself an empowered and informed health consumer!

Elective Inductions and Elective Cesareans - No Big Deal?

Think elective inductions or elective cesareans are no big deal?  Check out the abstract of this recent study.  [And remember the higher rate of inductions and "elective" cesareans in women of size and consider the implications there too.]


Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks' gestation. 

Dunne C, Da Silva O, Schmidt G, Natale R.  J Obstet Gynaecol Can. 2009 Dec;31(12):1124-30. Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.

OBJECTIVE: To compare maternal and neonatal outcomes after elective induction of labour and elective Caesarean section with outcomes after spontaneous labour in women with low-risk, full-term pregnancies.

METHODS: We extracted birth data from 1996 to 2005 from an obstetrical database. Singleton pregnancies with vertex presentation, anatomically normal, appropriately grown fetuses, and no medical or surgical complications were included. Outcomes after elective induction of labour and elective Caesarean section were compared with the outcomes after spontaneous labour, using chi-square and Student t tests and logistic regression.

RESULTS: A total of 9686 women met the study criteria (3475 nulliparous, 6211 multiparous).

The incidence of unplanned Caesarean section was higher in nulliparous women undergoing elective induction than in those with spontaneous labour (P < 0.001).

Postpartum complications were more common in nulliparous and multiparous women undergoing elective induction (P < 0.001 and P < 0.01, respectively) and multiparous women undergoing elective Caesarean section, (P < 0.001).

Rates of triage in NICU were higher in nulliparous women undergoing elective Caesarean section (P < 0.01), and requirements for neonatal free-flow oxygen administration were higher in nulliparous and multiparous women undergoing elective Caesarean section (P < 0.01 for each).

Unplanned Caesarean section was 2.7 times more likely in nulliparous women undergoing elective induction of labour (95% CI 1.74 to 4.28, P < 0.001) and was more common among nulliparous and multiparous women undergoing induction of labour and requiring cervical ripening (P < 0. 001 and P < 0.05, respectively).

CONCLUSION: Elective induction leads to more unplanned Caesarean sections in nulliparous women and to increased postpartum complications for both nulliparous and multiparous women. Elective Caesarean section has increased maternal and neonatal risks.

PubMedID: 20085677

 
Simplified Glossary: 
 
nulliparous - no previous births
multiparous - previous births
elective - (in this context) not medically necessary
NICU - Neonatal Intensive Care Unit

Choosing a Birth Care Provider - Which Type?

Some online friends of mine wrote this article for their local paper.  I gave feedback and helped during the editing process, and liked the final product so much I thought I'd share it here on my blog.  I offer it for those of you who are scratching your heads over figuring out how midwives and doctors differ. 

Again, I emphasize that no one type of provider is suitable for all women.  Some women prefer high-tech care with lots of tests and/or an epidural in the parking lot.  Some women prefer low-tech care, with minimal or no tests and birth as natural as possible.  Others want something in between.  There's nothing wrong with any of these types of births as long as you are clear on what you want and why.

Some women prefer that their doctors do all the decision-making, while other women prefer to be partners in their decision-making.  Some women prefer to birth in the hospital, and some prefer to birth outside the hospital (at a birth center or at home).

There no one "right" way to give birth for everyone. But if they explore their feelings, most people find they have ideals about how they want to be treated in pregnancy and birth, how they picture birthing their babies, and what kind of care they are looking for.  When I teach childbirth classes, I always encourage parents to explore the spectrum of possibilities and consider what fits best with their ideals.  In time, they usually find the right path (and provider) for them.

It's important to remember that the care provider's job title does not necessarily mean they practice in that same care model.  In other words, some doctors actually follow the hands-off tenets of the midwifery (physiological) model of care, while some midwives are high-tech and interventive like the medical (technological) model of care.  Although job titles and degree letters give you generalized clue to their practice style and philosophy, it's not a guarantee of anything.  You always have to ask questions.

Readers of the blog know that I tend to favor midwifery (as does the following article; fair warning) and have usually had my best experiences with midwives, but one of the worst experiences I ever had was with a homebirth midwife who was actually a high-intervention OB in sheep's clothing...at home, no less.  I also have met OBs who are very hands-off and low-tech.You can't tell someone's philosophy solely from their job title; interview carefully to see what their real pattern of practice is like.

I usually suggest that prospective parents interview several types of care providers, including some OBs, some CNMs, and some homebirth midwives.  Reflecting on these interviews usually helps clarify their choices for them.  Most people come away with a clearer idea of the type of care (and care provider) they prefer.

Here then is the article.  I hope you find it helpful.


Choosing a birth provider can be difficult

By Christa Billings and Amy Poe
From the Portland Tribune, Mar 25, 2010
http://www.portlandtribune.com/opinion/story.php?story_id=126946379588406800
Regarding Peter Korn’s article “Natural birth? Nope, C-Section rates on rise” (Feb. 18), one of the most important decisions new parents are faced with is choosing a birth provider. It is also one of the most difficult and confusing decisions to make.

The truth is that there is no one perfect location or type of provider for all women. We all come to our births with our own experiences, beliefs, personal health and genetics, and each mother has to come to know her own needs in order to choose the most optimal provider and setting for her birth.

There are two basic models of maternity care: the physiological (midwifery) model and the technological model (obstetrics). Each has its own advantages.

The physiological/midwifery model recognizes birth as a natural event. Care is centered on the woman and baby as a pair, and each pair is recognized to have its own set of experiences and unique health considerations. In this model, the birth providers spend a considerable amount of time with the parents, getting to know their physical and emotional needs and providing them with important information on their pregnancy and birth choices.

While the midwifery model emphasizes the partnership between the mother and provider in the birth process, the technological model views the birth provider as the expert whose job it is to control and manage the pregnancy, labor and birth. Normal birth is narrowly defined, and the provider is trained to treat any deviation from normal as a pathology needing intervention. The provider relies heavily on testing, monitoring and technological intervention in assessing and controlling the situation.

Statistically, both models of care can and do result in healthy babies most of the time. The primary differences between the two models are the type of care the mother receives during the pregnancy and her role in the actual birth – whether she is the active decision-maker (in partnership with her provider), or whether she delegates the control of her labor to an expert.

Naturally, it is always important to check the credentials and references of any provider you are considering, be it a direct-entry midwife, certified nurse-midwife, naturopath, family practice doctor, or obstetrician. But it is just as important to understand which model of care the provider practices, and whether that is compatible with your own beliefs about birth.

It’s important to realize that the provider’s title does not guarantee which model of care they practice. Midwives can order the same labs and screening tests as doctors, and some are very technology-oriented. Conversely, an OB-GYN may firmly believe in the normalcy and diversity of birth, and have a low technological intervention rate.

Midwifery care is a natural, holistic and wellness-oriented view of pregnancy and birth. Midwifery care focuses on the pregnancy as normal and healthy, rather than pathological. Most midwives believe in a proactive approach to wellness. They try to prevent complications in the first place by emphasizing healthy behaviors. If complications do arise, they take steps to work with you and your baby to deal with them instead of treating a complication like a disaster waiting to happen.

Time and patience can be one of the biggest benefits of midwifery care. Many doctors have strict time limits for labor, after which a cesarean is performed. Midwives believe that if the mom and baby are not in distress and all vital signs are reassuring, there is no need to hurry a birth. Every woman’s body and birth are different, and not all strictly adhere to a “typical” labor curve. Many babies come out naturally if given a bit more time and patience.

Many women have heard of midwives but are unaware of research showing improved outcomes with midwives. Examples include the interspecialty differences in the obstetric care of low-risk women, on the Web at www.ncbi.nlm.nih.gov/pubmed/9096532, and the outcomes of planned hospital birth attended by midwives compared with physicians in British Columbia, on the Web at www.cmaj.ca/cgi/content/full/181/6-7/377.

Midwives are experts in normal birth, and most births proceed normally, with good outcomes, if allowed a little time and patience. However, sometimes more intervention is needed, and midwives are trained to recognize when intervention or technology is needed. At that time, they have obstetric colleagues to whom they refer their clients, while still following up to assure continuity of care. It is at those times that we can be grateful for the surgical skills and capabilities of our obstetricians and hospitals.

Not only does midwifery care lead to fewer infections, inductions, episiotomies, vacuum/forceps extractions and cesarean sections, but midwives also tend to the emotional, spiritual, and health and nutritional needs of the mother from the start of the pregnancy through labor and birth and for several weeks after the baby is born.

Choosing your type of birth provider is a critical choice in your care. Oftentimes, parents spend more time researching and picking out nursery décor than they do choosing a provider who meets all their needs. For some women, an OBGYN is the right type of provider and for others it is a midwife. Taking the time to do your research on choosing the right provider for you can have an effect on the outcome of your birth.

Christa Billings of Beaverton, and Amy Poe of http://www.birthmatters.info/

Reply turned post: Ghettoizing Fat Pregnant Women

Kathy at Woman to Woman Childbirth Education has a good post on a recent article from the UK, discussing the banning of "obese" women from birthing in certain "low-risk" hospital birth units because of their weight.

I commented on her blog, but the more I think about it, the more I think it deserves its own post here on my blog too. So I'm going to hijack the discussion over to here.

This is part of a new trend towards "bariatric obstetrics." The idea is that the "obese" mother is at SUCH INCREDIBLY HIGH RISK that she is better off delivering at a hospital that is specially equipped for her needs and where doctors can specialize in such "high-risk" deliveries.

Although some folks setting up these policies may have good intentions, what they are actually doing is "ghettoizing" fat women.

By taking away low-risk care options for fat women, they virtually guarantee a high-risk, high-intervention, high-complication delivery for them.

But no one is actually studying whether switching to special "bariatric obestetrics" practices and hospitals actually improves outcomes among "obese" women. They just assume it does.

And it assumes a level of extreme risk for all fat women when many don't experience that at all.

Yes, pregnancy in women of size has more risks of some things, like gestational diabetes, pre-eclampsia, macrosomia, etc. Yes, some women of size have complications. You'll never hear me pretending otherwise. And sometimes a woman of size does have complications that needs a higher-intervention approach or a higher-risk hospital or practice.

But many women of size have healthy pregnancies and births, and many more probably could if they access to proactive, low-intervention care via the midwifery model of care.

If fat women don't have any complications, do they really need a high-risk practice or location, based on weight alone? Do they really benefit from it? Or does it cause more harm than benefit?

And even those who experience mild complications, can't they usually still be cared under the midwifery model of care and benefit from that model?

Research shows that when comparing clients of the same level of risk, midwifery clients experience fewer inductions, fewer augmentations, fewer epidurals, fewer episiotomies, and fewer cesareans, yet their outcome is just as good or better.

Some research suggests that women of moderate risk also benefit from the midwifery model of care. Although not specifically addressing obesity alone, Cragin and Kennedy 2006 concluded,

Even among moderate-risk patients, the midwifery model of care with its limited use of interventions can produce outcomes equivalent to or better than those of the biomedical model.

To take away the choice for that low-intervention model across the board based only on size, regardless of actual complications, is a total miscarriage of justice.

And I think that's the thing that has me most enraged....the paternalistic, condescending attitude of making my decisions for me, for my own "good"....because I'm fat. Taking away my best chance of having a safe, unintervened-in birth....because I'm fat.

As Susan Hodges of Citizens For Midwifery states, "How much 'risk' does it take to supercede the mother's right to bodily integrity?" Or self-determination?

I've got news for these folks. My weight does not give you the right to make my choices for me or to dictate whom I can see or what kind of birth I am "allowed" to have. This is my body, and *I* get to decide.

Unable To Access Low-Tech Care?

Unfortunately, I think that more and more in the next few years, we will see fat women denied the right to obtain low-risk maternity care, the right to see midwives, and the right to have homebirths or birthing center births.

It's already happening. Some birth centers already deny access to women above a certain BMI or weight limit. Some homebirth midwives/doctors turn away "obese" women, even those without complications, simply based on their weight.

Some homebirth midwives want to serve women of size but know that if there is a transfer or anything goes wrong, the authorities in their area will skewer them for daring to care for an obese woman at home.

(It's already happened; a friend of mine recently planned a homebirth and her midwife backed out on her for this very reason. She eventually found another midwife but it was not easy to find one so late in pregnancy. Fortunately, the birth went fine and no one got taken to task for serving a fat woman at home....but the fact remains that the fear of this caused her first midwife to desert her, and near the end of pregnancy too.)

So more and more fat women---even those who want alternative, low-tech care---are being forced into the high-tech medical model, one in which "morbidly obese" women often end up with a nearly 50% c-section rate---or more.

In fact, even being forced to be in the hospital with an OB isn't enough now. Some hospitals (like this one above in the UK or this one in Australia) are forcing fat women into specialized centers, so that they can't even access the low-risk, low-intervention hospitals.

And some regular OB practices refuse to care for obese women, requiring them to instead see high-risk OBs....regardless of whether they actually have any complications or not.

To these providers, the mere fact of being "obese" is complication enough, even without any actual complications to inconveniently complicate their biases, so to speak.

In other words, the hyperbole of risk around fat mothers is so out of control now that we are ghettoizing them. And it's only going to get worse.

Show Me The Money, Baby

The real question here is whether the centralizing of "obese" women together into specialized centers and under the "high-risk" umbrella improves outcomes or not.

My bet is that it simply leads to an atmosphere of unchecked and unquestioned intervention, and many many unnecessary cesareans.

But we don't know that because no one is documenting the outcomes. As far as I can tell, no one is even asking the questions.

Where is the proof that these bariatric specialties improve outcome?

Where is the publication of the protocols routine to these bariatric obstetrics practices? Are all these women being told to diet during pregnancy? Are they all being induced early for fear of a big baby? If they go outside the approved protocols of xxx pounds of weight gain or xxx pounds of expected baby size, are they just automatically sectioned?

Where is the documentation of the intervention rates of these practices? What is the induction rate, what is the c-section rate, what is the VBAC rate, what are the complication rates?

Where is the prospective study of high-tech, high-intervention specialized bariatric care for obese women, compared to a control group of women of similar size and complications who instead are exposed to the low-tech, low-intervention midwifery model of care?

Show me the money, people. Ah, but that's the problem right there. This is a new cash cow in obstetrics these days....the specialized practice of "bariatric obstetrics."

Just think of all the money they can charge insurance companies to force these women to see bariatric specialists! Just think of all the money they can charge for "specialized" bariatric equipment! Just think of all the billable services they'll "need" in the hospital! And just think of all the extra money from all the extra c-sections!

Sorry, I don't care if you have no financial incentive to study this or not. You have to SHOW ME that this high-tech, high-intervention, high-risk attitude towards birth in "obese" women actually improves outcomes before you dictate where I "have" to give birth in order to birth "safely."

PROVE IT. In a good study, with a good control group of similar fat women being treated in a true low-intervention midwifery model to compare it with.

Until then, stop taking away the rights of women of size to birth where they want to, to have equal access to low-tech birth, to have equal access to "alternative" techniques like waterbirth and full mobility in labor.

Stop forcing fat women to have early epidurals "just in case," mandatory internal monitoring, and automatic confinement to bed. Stop pushing fat women to induce labor early "before the baby gets too big." Stop sectioning fat women whose weight gains or whose baby size fall outside your definition of "desirable." And stop forcing women into bariatric obstetrics practices and high-risk hospital wards if they don't want it or need it.

Stop ghettoizing fat women, damn it. And stop telling us how and where we are "allowed" to give birth. These are our bodies and our babies, and we are the ones who get to have the final say.