"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.

The Fat Vagina Theory Strikes Again

Here is a story someone left as a comment on my post on Soft Tissue Dystocia.  The story, unfortunately, is all too common.

As I explain in the Soft Tissue Dystocia post, some care providers believe that very fat women have so much fatty tissue in the pelvic area around their vaginas that a baby is unlikely to get out safely. 

Officially this is called "Soft Tissue Dystocia" but sometimes in the birth world we cynically call it the Fat Vagina Theory, based on a term that has actually been used by some doctors to explain to women of size why they had a cesarean.

Unfortunately, Fat Vagina Fear is yet another factor helping to drive the high cesarean rate in women of size.

Attack of the Killer Vagina

As I note in my previous post, there's little scientific evidence about soft tissue dystocia; it's mostly a dogma that has been taught to care providers over the years as if it is a hard-and-fast truth.....without the inconvenient detail of actually having proof.

But it's a dearly-held dogma, and one that care providers rarely even question. And the belief in it leads to many questionable interventions in women of size.

Providers who subscribe to this dogma believe that vaginal birth in very fat women is unlikely because of so much soft tissue in the way, or that the combination of a big baby and this "compromised" pelvic space will cause the baby's shoulders to get stuck, resulting in injury and lawsuits.

Therefore a common response to Fat Vagina Fears is to either schedule a cesarean or to induce labor early while the baby is theoretically more able to fit. 

Unfortunately, research shows that inducing early for a big baby leads to a higher rate of cesareans, not a lower one, and may actually increase the rate of shoulder dystocia. 

Let's say that again.  The intervention they use to supposedly lessen risk may actually cause the very outcomes they are trying to avoid─yet they still do it anyhow.

The results are no better for a planned cesarean before labor.  Babies don't do any better and moms' outcomes are worse.

To be fair, some of these care providers may have good intentions.  Those who routinely section high-BMI women often do it because they are convinced that labor is likely to end in a c-section anyhow, and because they feel it's better to do the "inevitable" c-section under planned conditions instead of emergency ones. 

Those who induce big moms early often do it because they feel inducing at least gives the mother a chance at vaginal birth, and because they feel they are less likely to get sued if they can show they took proactive measures ─ like inducing early.

Their intentions may be benign, but their interventions are not.  They don't improve outcomes, and often cause MORE complications than they avoid. 

Yet early inductions or planned cesareans with "obese" patients remain a very common practice, often with "soft tissue dystocia" as part of the reason.

Some providers are even beginning to be hassled if they don't follow these practices with women of size, as if they are behaving dangerously by not inducing or doing a cesarean.

One Mother's Story

This story sadly illustrates this scenario. The mother was induced at 37 weeks because of her size and the doctor's fear of shoulder dystocia. 

Not surprisingly, it led to a cesarean.  However, because the baby was not ready to be born, he had to go to the NICU and the mother didn't get to even hold her baby─for nearly a week. 

Although most care providers now wait longer than 37 weeks to induce for suspected macrosomia, the story often ends very similarly.  Mom's body is not truly ready for labor, baby is not in a good position yet, a long hard induced labor follows, and the mom ends up sectioned for "failure to progress," fetal distress, or fear of infection after a prolonged induction.  Women are told their babies were too big, their vaginas too fat, or their pelvises were too small ─ but the real reason was that inducing before the mother/baby dyad is ready often ends in cesarean.

Afterwards, Mom and baby are often separated, sometimes for hours, sometimes for days, which is one of the most difficult and heartbreaking things for a new mother.  Breastfeeding often gets off to a rocky start, and mother has to try and learn to care for her new baby while she is recovering from surgery.  Not a recipe for an easy transition into motherhood, and one which probably negatively influences the rate of breastfeeding in women of size.

Alas, the Myth Of The Fat Vagina is alive and well in obstetrics, and combined with Fear Of The Monster Baby, helps drive the cesarean rate in women of size. 

I had a c-section with my first baby seven years ago.

I was "warned" by my OB that since I was so big, 330, and had more fatty tissue in my vagina, that I could put my baby in jeopardy trying to deliver him naturally. She told me that i could break his collarbone, dislocate his shoulders or he could just get stuck.

I went against my gut and allowed myself to be induced 3 weeks early. When my doctor came in to check on me after the first couple of hours, she broke my water without my consent and the clock started ticking. After 24 hours of labor, I was so close and my doctor ordered me into an emergency c-section because my water had been broken for too long, putting my baby at risk.

Adding insult to injury, I had not had any pain medicine (I'm kind of granola). The anesthesiologist came in to give me the epidural and took one look at me and said that it is really tricky to do on such a fluffy girl. I begged for her to try. She told me that she was going to give me some oxygen before she started and put me to sleep. I woke up so confused. And worst of all I feel I missed the birth of my son.

He was very sick and had under developed spots on his lungs, he was taken away to the NICU immediately. I didn't get to hold him until he was 6 days old.

I really wish that I had trusted my instincts and had had a provider who listened. I am pregnant again. I am prayerful that this time around I will be able to have a natural birth free from all of the bullying that I experienced before. I have to believe that my body, big or not, would not grow a baby that it could not deliver.

*I hope this mom contacts ICAN, the International Cesarean Awareness Network, which can help her work through her feelings about her cesarean, find a more size-friendly provider, and support her as she works towards a VBAC. 

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. 

The Fat Vagina Theory: "Soft Tissue Dystocia"

One common misconception that many birth attendants have about labor in women of size is the "fat vagina" theory.

In this theory, birth attendants believe that women of size have a lot of extra fat tissue internally, crowding the maternal pelvis and birth canal.  Extra fat tissue then supposedly gets in the way and obstructs the passage of the baby through the bony pelvis and/or vagina.

In medical research they call this "soft tissue dystocia," but sometimes doctors will patronizingly explain it to patients as the "fat vagina" theory.

[Note: "Fat Vagina" is an actual term used by an OB to tell a friend of mine from ICAN why she had a cesarean ─ she was told her morbid obesity made her vagina "too fat" to let the baby out during labor ─ and she's not the only one who has been told that.  So although my sarcasm meter is certainly on when I use it, that's really a term that has been used with some women of size.]

Alas, it's not just doctors who buy into the "fat vagina" theory.  One TV birth show featuring a midwifery practice even promoted this same theory, encouraging a fat woman who wanted a Vaginal Birth After Cesarean (VBAC) at their birthing center to lose weight during pregnancy in order to "decrease the fat deposits in the vagina" and "make it possible" for the woman to have a VBAC. (As if no fat woman has ever had a VBAC without losing weight!  Sorry, they have. And so have I.)

Or there's the story one of my blog's readers emailed to me:

[The midwife] said I will have a large fat buildup around my birth canal and uterus so baby will get stuck in a natural birth. 

Alas, this "fat vagina" belief is a theory near and dear to many birth attendants' hearts.  They have been taught in medical or midwifery school that "soft tissue dystocia" is the cause of many cesareans in fat women, and they believe it with all of their hearts.  It's very difficult to get them to question its existence. 

But what does the evidence say? 

The Research, Such As It Is

One of the most frustrating aspects of the whole "fat vagina" theory is how little actual evidence there is on it, yet it is taught as if it is clearly established science. 

One study (Crane 1997) describes it as a possible reason for a higher primary cesarean rate in "obese" women:

Perhaps dystocia due to an increased deposition of soft tissues in the maternal pelvis may lead to the observed increase in the cesarean delivery rate.

One review (Vahratian 2005) noted that many studies attribute the increased rate of cesareans in "obese" women to soft tissue dystocia but that few prove it.

Several authors have speculated that this association [between obesity and cesarean rates] may be due to the added soft-tissue deposits in the pelvis of obese women, which coupled with a larger fetus might necessitate more time and stronger contractions to progress through labor.  However, direct evidence of fat deposition in the pelvis is needed to support this assertion.

The study noted that as yet, the authors promoting this theory have failed to provide this evidence.

Most studies discuss increased maternal fat deposits as if it is a proven concept, but no one has actually done much study showing a real difference in maternal fat compartments, let alone proven that it affects labor.

Barau et al., 2006, also favors the concept of soft tissue dystocia but acknowledges that:

There is no direct support of this concept by medical imagery studies.

So why are healthcare providers so devoted to this theory when there is very little actual proof of it? 

Most of the time, practitioners believe in the concept of soft tissue dystocia because they know that visceral fat can build up around internal abdominal organs, so they speculate that a similar thing must be happening in the maternal pelvis.

Furthermore, they often observe more tissue during pap smears in "morbidly obese" women, sometimes needing to use a larger speculum in order to hold open the vaginal vault and do the exam.  Therefore, they jump to the conclusion that there is more fat "crowding" the pelvis of women of size, and that therefore, this must be obstructing the passage of the baby through the mother's pelvis.

But just because a fat woman's vagina tends to have more tissue to hold back with a speculum does not necessarily mean that there is enough fat way up inside the pelvis (pelvic inlet) or at the pelvic outlet to be clinically significant.  

Remember, because the considerable weight of a fat woman's abdomen presses down with the weight of gravity, it may tend to make the vaginal walls more prone to collapse and look overly crowded, but it may not actually be so, or not enough to make much difference. And even if there was somewhat more tissue in a fat woman's vaginal area, remember......fat squishes.  It's unlikely that there would be enough tissue there to actually impede a baby's exit, even in very fat women. 

The one study we do have that actually did medical imagery to discover whether there are extra maternal fat deposits in the pelvis does not support the idea that there is enough extra soft tissue to be relevant to birth.

Wischnik (1992) did a study on the "fatty pelvis" to see whether fat compartments within the pelvis actually resulted in "functional reduction of the birth channel diameters."  They found slightly more fat compartments, but did not find it to be clinically relevant.  They concluded:

The common assumption can no longer be maintained, that adiposity necessarily causes soft tissue dystokia  [sic] due to larger fat compartments within the small pelvis.

So from a strictly evidence-based point of view, there is no substantiated medical evidence of enough increased deposits to be medically significant. 

All we have is the observation that there is slightly more tissue pushing in and thus more need for a stronger speculum during the pap smears of women of size. 

I think most medical providers then take a leap of logic and conclude that if fat women's babies don't come out as easily as skinny women's babies, it must be due to fat blocking the way....and the need for a bigger speculum during a GYN exam in some women of size just seems to confirm that bias. 

But I think they need to look more closely at this assumption.

Alternative Explanations

Unfortunately, despite a glaring lack of evidence, soft tissue dystocia is a concept that continues to be taught and widely believed. 

Barau 2006 argued that although there is no hard proof of soft tissue dystocia, it must exist because there is an increase in cesareans due to prolonged labor in obese women compared to average-sized women with similarly-sized babies. 

However, I will point out again that a higher rate of malpositioned babies among women of size could also explain their longer labors and increased rate of cesareans due to labor dystocia.

Babies who face their mothers' tummies (occiput posterior) don't fit as easily through the pelvis, present with a larger head diameter, and often experience long, slow, hard labors.  Research clearly shows that posterior babies have longer and slower labors and have a much higher cesarean rate than anterior babies. 

Although the subject needs further study, some research has found a higher rate of malpositioned babies in "obese" women, and very old obstetric research also often notes in passing a higher rate of occiput posterior and other malpositions in women of size as well.

And anecdotally, women of size often do seem to have more malpositions, especially occiput posterior, many of which result in cesareans.

Many of these fat women have been told they had cesareans because of their "fat vagina" or "too small" pelvis.  Yet if you read their stories carefully, they had all the signs and symptoms of a malpositioned baby instead. 

Furthermore, many women who had cesareans for "fat vaginas" went on to have subsequent vaginal births with babies that were even larger than their cesarean babies....without losing weight first. This would be impossible if the problem really were a "fat vagina." 

The key was having a well-positioned baby, not losing weight or reducing maternal pelvic fat deposits. 

Another problem with the concept of the "fat vagina" is the inconsistency with which this diagnosis is applied. If a ~275 lb. woman (like my friend from ICAN) is told that her vagina is "too fat" and prevented her baby from getting out, then it follows that a 350 lb. woman should not be able to birth a similarly-sized baby vaginally. Yet we know that women of that size can and do have vaginal births. I have birth stories on my website of vaginal births to women at 300, 350, and 400 lbs.  Yes, women of this size have a high cesarean rate because they are almost never given a real chance to actually have a vaginal birth.....but it can happen when they are given a realistic chance.

If fat vaginas truly prevented vaginal birth as much as some providers think they do, there would be NO vaginal birthers above a certain size. Sure, vaginal birth is always a combo of factors, including pelvic size/shape, the baby's size and position, (passenger, powers, position, etc.), so some variability in who gives birth vaginally is logical, but if soft tissue dystocia were a really significant factor, really supersized women would never birth vaginally.  Yet many can and do, if they have a well-positioned baby and are given a realistic chance.

In my opinion, the real issue behind a higher rate of "dystocia" cesareans in women of size is probably fetal position, not fat vaginas. 

However, because doctors are trained to blame obesity as the go-to diagnosis when they don't have another explanation, soft tissue dystocia gets blamed for "blocking" the baby's way out. 

But that's just lazy thinking, not actual proof of soft tissue dystocia.

What About Shoulder Dystocia?

Another fear that many doctors and midwives have is that extra soft tissue in a fat woman's vagina might cause such a tight fit for the baby that the baby's shoulders will get stuck ("shoulder dystocia"), which can be a true obstetric emergency.

This fear seems borne out by studies which have shown higher rates of shoulder dystocia in "obese" women. Yet many of these studies did not control for other factors, like macrosomia, diabetes, forceps/vacuum extractor, or induction, all of which increase the risk for shoulder dystocia, and most of which occur at higher rates in women of size. 

It's important to note that other studies have found that obesity is not a risk factor for shoulder dystocia when these other factors are controlled for. 

Furthermore, it is not extra fat crowding the vaginal walls that causes shoulder dystocia. Rather, shoulder dystocia is caused by obstruction by the bony pelvis, not soft tissues. A complex interplay of factors results in shoulder dystocia, including fetal position, maternal position and mobility, pelvic shape, induction, operative delivery, diabetes, and macrosomia. 

But justified or not, fear that "extra" soft tissue will cause shoulder dystocia is a big contributor to the high planned cesarean rate and early induction rate in women of size. 

But What If Soft Tissue Dystocia is Real?

Frankly, soft tissue dystocia as a concept has not been proven at all, but some care providers believe in it with all their heart and refuse to be dissuaded from the possibility, pointing out that it hasn't been disproven conclusively either.  That's a fair point.

To these providers I would argue that IF soft tissue dystocia were indeed real, then it is vital to change how most providers manage the labors of women of size in order to minimize its theoretical impact.

The typical way the labors of many "obese" women is managed often includes inducing early, breaking the bag of waters early, strongly encouraging early placement of an epidural "just in case," strictly limiting mobility, and using semi-sitting or lying back positions for pushing. Yet these measures often limit the amount of pelvic space the baby has to fit through.

If a bunch of extra fat is supposedly crowding things already, these restrictive protocols just make things worse.

IF soft tissue dystocia were real, mobility in labor would be even more important to women of size because it opens up the pelvic dimensions and gives "obese" women the best possible chance to help that baby fit through. Yet "obese" women have the most restrictions on their mobility in labor and are the least encouraged to try alternative positions for birth.

If a provider truly believes that soft tissue dystocia might be real, then the answer is not to pre-emptively induce or section women of size, but to give them every chance at creating more space in the pelvis. 

This means not having her in the usual lying back/semi-sitting position, which puts pressure on the tailbone and presses it into the pelvic cavity, reducing the space available. 

This means not requiring/pressuring her for an early epidural (as many practices encourage with women of size), so that she can move freely during labor and encourage her baby to be in a good position for birth. 

It means not breaking her waters early in labor, so the baby has the watery cushion to help it move into an optimal position. 

It means letting her stay upright as much as possible, so she can use gravity to help bring that baby down and press it through those supposedly fat-crowded walls. 

It means letting her push in whatever position feels comfortable to her, encouraging her to stay mobile, and letting her utilize things that will help her stay mobile more easily (a labor tub, a dangling support or trapeze bar, a squat bar, etc.).

Personally, I don't believe that soft tissue dystocia is clinically relevant, but if you are a provider and you firmly believe in its existence, follow that to its logical conclusion and utilize labor protocols that help that woman maximize her pelvic space, not inhibit it via restrictive protocols. 

Conclusion

Soft tissue dystocia is a belief that is near and dear to many doctors' hearts (and sadly, even to some midwives' hearts). Yet despite no research to support it, it as taught as if it is fact. 

At this point, soft tissue dystocia is NOT fact.  It has not been proven at all, and remains highly speculative as a possible cause of labor issues.

Furthermore, many women of size who have had their cesareans blamed on "fat vaginas" have gone on to have vaginal births in later births----without having lost weight first.  If soft tissue dystocia were really the cause of their cesareans, this would not have been possible. The issue for them was fetal position, not maternal soft tissue. 

The "morbidly obese" friend of mine who was told that her "fat vagina" was the cause of her cesarean?  She has since gone on to have TWO vaginal births.....at the same maternal weight, with similarly-sized babies.  So much for her "fat vagina" preventing the baby from coming out! 

And then there's the commenter on my blog who had a similar experience: 

I was told by my OB, while on the operating table and again at my 6 week check, that 'my vagina was too fat to birth a baby naturally'. Had a VBAC 3 years later though!

[Comment on 10-12-10, on Prenatal Weight Gain: The Importance of Study Design.]

Far too often, "fat vagina" is just a convenient excuse for lazy thinking, a handy scapegoat for the high cesarean rate in women of size, and a convenient excuse for blocking access to VBAC in yet another group.

And unfortunately, it prevents caregivers from examining their own care practices and how iatrogenic influences like weight bias, induction, fear of macrosomia, restrictive protocols, "failure to wait" and fetal position issues are the real factors driving the cesarean rate for women of size.  

Third Annual Turkey Awards: Jumping To Conclusions

Well, it's that time of year again.....time for my Annual Turkey Award!

This is an award I created to annually "honor" fat-phobic healthcare providers everywhere.  And believe me, there are plenty of them...a veritable cornucopia of turkeys to choose from for this delightful award.

This year, I want to highlight the caregivers who have made the leap of logic that if a fat woman is at increased risk for a complication, that means there's a GUARANTEE that she will experience that complication. 

Like the recent commenter to my blog who was told that at her size, she WOULD have a deformed baby.  Not a reasoned discussion about possible increases in risk for birth defects or ways to possibly lower that risk, but the doctor telling her that she WILL experience a "deformed" baby, simply because of her size.  Never mind that the chance is actually quite low in terms of actual numbers, the doctor just concluded that it WOULD happen because of her weight.

Or another reader who recently sent me an email about her first pregnancy appointment, where she was lectured about her fat and basically informed she "should neither expect or deserve to have a healthy baby." 

Or there are the the doctors who tell fat pregnant women that they WILL get pre-eclampsia or they WILL get gestational diabetes during their pregnancies.  No discussion of actual numerical risks (which show that the risk, while increased, is still relatively low), no discussion of things they might do to help mitigate that risk ─ just the assumption that these complications WILL occur in all women of size.

[Yes, there are increased rates of PE and GD in women of size, but there is NO study that shows a 100% rate of pre-eclampsia or gestational diabetes in "obese" women, "morbidly obese" women, or even "super-obese" women.....not even close.]

Or there's the recent spate of doctors telling "obese" women that if they try to have a VBAC (Vaginal Birth After Cesarean), they, their baby, or both WILL die (or have a very low chance of survival).  Never mind that there's NO actual evidence to support an increased risk for maternal or fetal death among fat women trying for a VBAC; who needs evidence?  They just know that it's far too dangerous for fat women to even try and therefore fat women shouldn't even be allowed the choice.

This is one of the major problems with over-emphasis on the risks of "obesity" in public health campaigns. People begin getting a distorted picture of the actual numerical risk.

In time, a numerically-low-but-somewhat-increased-risk for a complication somehow gets transformed into a widespread perception that ALL fat people will experience that complication and eventually the perception develops that DEATH will be the inevitable result.

This exaggerated ramping of risk perception occurs even among healthcare providers, who really ought to know better, and in the end, results in people's choices and autonomy being taken away from them.

It's not that we cannot discuss possible risks.  Of course we can; that's an important part of the healthcare conversation.  However, public health discussions about "obesity" have gone from discussing possible risks realistically and without judgment, to making sweeping generalizations and exaggerations of risk in the public's mind, to scapegoating, barbaric scaremongering, and suspension of basic rights by healthcare professionals.

You know things have gone too far when even healthcare professionals are believing the scaremongering sensationalism that goes against every bit of science and reason that they should have been trained to employ, and when they suspend every sense of medical ethics they have been taught.

*Turkey image from Wikimedia.

Exaggerating the Risks Again

Here we go again. 

Yet another article has been published in the mainstream media (the New York Times, disseminated through its news service), hyperventilating about the risks of "obesity" in pregnancy.  And it includes the typical distortions, exaggerations, and apocryphal personal stories as part of  the usual tactics to scare fat women into either drastic measures to lose weight before pregnancy, into draconian interventions during pregnancy, or to scare them out of even contemplating pregnancy at all. 

We've covered this territory before, and I'm sure we'll cover it again in the future, but let's chat about why this is more scare tactics and marketing than anything else.  I don't have time right now to do a detailed smack-down of the numbers and studies but we'll talk about the main problems with the article.

Lack of Use of Real-Life Numbers

First, they need to stop discussing the risks of "obesity" in pregnancy exclusively by the means of odds ratios, which distort the sense of risk around an issue.  Include the real-life occurrence of such problems, so women of size can assess for themselves just how risky (or not) something is. That helps put the risk in better perspective.

For example, the article states that there is a higher rate of birth defects in "obese" women.  And it's true that some studies have suggested that there is 2-4x the risk for birth defects in obese women.  Sounds scary, doesn't it?

Yet rarely do the studies (and especially the press releases) mention that doubling a very small risk is still a very small risk.  Yes, the risk for Neural Tube Defects in "obese" women seems to be increased in some studies, but even so, the actual numerical risk is still likely less than 1%. 

That means that 99% of "obese" women will not have a baby with a Neural Tube Defect.  Do you come away from reading these stories feeling like the actual risk is that small?

Although odds ratios can be useful at times, be careful when articles don't also include the actual numerical occurrence. It's too easy to distort the sense of risk around something otherwise.

Distorted Risk Perspective

The article mentions prominently that "obese" women are more likely to have diabetes and high blood pressure complications.  This is true, and definitely a concern.  But the article fails to mention that most obese women will not experience these complications. 

For example, Weiss (AJOG, 2004), a large study of more than 16,000 women in multiple hospital centers, found that 9.5% of "morbidly obese" women (BMI more than 35) experienced Gestational Diabetes during their study.  The number certainly is higher than the 2.3% with a BMI less than 30, so it is definitely a risk (4x the risk---gasp!) that should be communicated to women of size. 

However, it also means that 90% of "morbidly obese" women did not develop Gestational Diabetes.  So while the risk increased, it should be remembered that the vast majority of morbidly obese women will not get GD. 

Pre-eclampsia is another risk that is substantially increased in "obese" women, and this one can be life-threatening to both mother and baby.  It is definitely a risk that must be discussed as a possibility and taken very seriously.  But in the Weiss study, only 6.3% of "morbidly obese" women developed Pre-eclampsia....higher than the 2.1% of non-obese women (3.3x the risk---gasp!) who developed PE, but hardly universal.  Remember, 93% of "morbidly obese" women did not develop Pre-eclampsia in that study. 

Again, the majority of these women did not get GD or PE, the two most common risks for women of size.

So while these risks are real and it's only sensible that the possibility be discussed with women of size (and that women of size be proactive about lessening their risk for them), it's important that the magnitude of the risks not be exaggerated or to imply that such a complication is virtually inevitable. 

[For the data wonks: Every study finds a somewhat different range of occurrence of these conditions, so you can definitely find studies out there that find both higher and lower rates of GD and PE than the Weiss study cited here.  However, many of these studies have significant weaknesses (too-small sample size, differing thresholds for defining various things, lack of recognition of the role that iatrogenic interventions may play) so each study must be vetted carefully.  The Weiss study is a multi-center study, has a very large sample size (16,000+ patients), and has information about a number of common risks, so it is a fairly robust study to use to look at the rates of these complications.]

Correlation Does Not Equal Causation

Another common mistake these articles make is to conflate correlation with causation.  The implication is that if anything goes wrong, obesity itself caused the problem, and therefore the solution is easy.....just lose weight beforehand.

But if being fat caused all these various complications, all fat women would get the complications, and they do not.  Furthermore, many women of average size get these complications too.  The picture is more complicated than simple cause-and-effect.

Another possible theory is that underlying metabolic differences is really behind these complications, and the fatness is merely a byproduct of these metabolic differences, a symptom if you will. 

Making the women diet will likely not help much unless the underlying metabolic differences are also addressed.  Trying to fix things by losing large amounts of weight is too simplistic an approach.

Furthermore, losing weight carries risks as well.  Women who lose a great deal of weight before pregnancy tend to have large weight gains during pregnancy as their body compensates, and that has its own risks.  Losing weight before pregnancy also puts the woman at risk for nutritional shortfalls, a big concern just when nutritional demands are about to be at their peak. 

A simplistic cause-and-effect view of obesity and complications can lead to many dubious conclusions and harmful therapies.  Yet researchers and authors continue to conflate correlation and causation in obesity research all the time.

Simplistic Approach

Another consistent problem with articles like these is their simplistic treatment of obesity and fat people's health habits.  But fatness is not a simple topic. All fat people are not alike and therefore one "fix" for them all is unlikely to work.  It may even harm. 

Some folks really are fat because they eat poorly and don't get enough exercise, and some folks really are fat because they have an eating disorder.  But research clearly shows that fatness also has a very strong genetic component.  Some people have underlying hormonal or metabolic disturbances (like PCOS) that create a propensity to being fat and great difficulty in losing weight.  Environmental factors (easy access to highly processed foods, less opportunities for exercise) plays a role for some people, yet many thinner people eat highly processed foods and get little exercise but are not fat.

There simply are no easy answers as to why some people are fat and some are not, but researchers and authors of articles like these want to pretend that there are because it makes them feel better.  They want to continue the simplistic mantra that fat people are fat simply because they eat terribly and get little exercise.  They want to believe that if everyone just ate right and exercised enough, everyone could be "normal" in size and therefore all complications from obesity could be avoided.  But this is not realistic and the abysmal long-term success rates of weight loss studies demonstrates this all too well.

Emphasizing health instead of weight may be a better approach, and might help prevent some of the complications, regardless of whether a person actually experiences weight loss.  For example, research shows that regular exercise can lower the rate of Gestational Diabetes in fat women.  It may or may not help them lose weight, but it can lower the rate of GD. 

And we must not forget that multiple weight loss attempts are often associated with greater weight gain in the long run.  Ironically, by emphasizing weight loss as the main "cure", doctors are likely recommending the one thing most likely to actually cause a worsening of fatness in the long run. 

Doctors and researchers want simplistic answers because then they can feel like they can "fix" things for women, but the answers are rarely that simple.  The best "fix" for obesity-associated concerns may be to emphasize health habits rather than weight loss.

Ignoring the Risks of Intervention

Doctors like to "do" things when presented with a possible risk, but they are slow to realize that sometimes the "doing things" does more harm than good or causes the very problem they are trying to prevent. 

For example, one of the things that really frustrated me when I read the article was the following:

Very obese women, or those with a B.M.I. of 35 or higher, are three to four times as likely to deliver their first baby by Caesarean section as first-time mothers of normal weight, according to a study by the Consortium on Safe Labor of the National Institutes of Health. 

While doctors are often on the defensive about whether Caesarean sections, which carry all the risks of surgery, are justified, Dr. Howard L. Minkoff...said doctors must weigh those concerns against the potential complications from vaginal delivery in obese women.

The implication here (and alas, many doctors share this perception) is that cesarean sections in women of size are safer than vaginal birth.  Barring major complications, nothing could be further from the truth. 

The truth is that cesarean sections are FAR more risky than vaginal birth for all women, and especially so for "obese" women.  There is the risk of anesthesia complications, hemorrhage, blood clots, and a very serious risk for infection.  Doing surgery on a very fat woman is complicated, and the relative lack of vascularity in adipose tissue means that oxygenation and therefore healing is more difficult. 

Yet despite the documented increased risk from cesareans to "obese" women, more and more doctors are doing them pre-emptorily.  They have such an exaggerated sense of risk around vaginal birth in women of size that they no longer are willing to let fat women even try.....or will only "let" them try if they induce labor early.  And therein lies the answer to much of the high cesarean rate in women of size.

Virtually every study shows an increased rate of inductions in women of size.  We know from other studies that high rates of induction often result in high rates of cesareans, but none of the studies on cesarean rates in obese women actually connect the dots and acknowledges that their excessive induction rates may be a primary cause of the high cesarean rates.  Nor does this article bother to mention this possibility. Instead it implies the obesity causes the cesareans. (Again we're back to correlation versus causation.)

If fat really prevented giving birth vaginally, it would have done so in the past too. But if you look at studies from the past, the cesarean rate in "obese" women was similar to that of average-sized women.  Obesity doesn't cause cesareans.  What has changed is the PERCEPTION of risk around women of size, and the MANAGEMENT of their pregnancies and labors, and that has resulted in higher cesarean rates. 

Being perceived as high-risk and treated as high-risk often creates a self-fulfilling prophecy. 

Doctors are so fearful about the hyperbole around obesity and pregnancy that they seek to control this sense of risk by overusing early inductions and planned cesareans, but there is no proof that this improves outcome.  Instead they merely expose women of size disproportionately to the substantial risks of surgery.

Using Worst-Case Scenarios To Scare Women

Another typical tactic in these stories is using a fat woman with a worst-case scenario story and implying that this experience is common. 

Ironically, the women in these stories typically aren't even very fat.  This illustrates the point they want to make of Just.How.Dangerous.Obesity.Must.Be because this terrible thing happened to a woman who was not even that fat!!  [Imagine the risks for a woman who was really fat!!!]

One of the first scary newspaper stories I read years ago about pregnancy and obesity used a moderately fat woman (less than 200 lbs.) as its bad-mother example. She developed pre-eclampsia, the placenta abrupted, and her baby died.  The article ended with the woman swearing to lose weight so that the same thing wouldn't happen next time. The implication was that if she developed pre-eclampsia and a stillbirth at her weight, all the bigger fatties out there had no hope. 

I remember the article because I'd just had my first baby. I was quite a bit heavier than she was and yet I hadn't developed pre-eclampsia, I didn't have an abruption, and my baby didn't die.  Either I was a walking miracle or the risk of pregnancy in someone my size might be more variable than they were implying. (I was just glad I had read the article after I'd had my baby, or I would have been terrified.....as they no doubt wanted me to be.)

In the New York Times article a woman named Patricia Garcia is used as the bad-example-du-jour.  She had a stroke during pregnancy, she developed pre-eclampsia, and her baby had to be delivered 11 weeks prematurely because its growth was not progressing properly. 

The study mentioned in passing that she had a "constellation of illnesses related to her weight, including diabetes and weak kidneys."  This makes it sound like her weight is to blame. 

But if so, why don't most fat women have diabetes and resulting kidney damage during their childbearing years?  Only a small percentage of fat women have pre-existing diabetes before pregnancy. And if this was caused by weight, why aren't we then seeing very high rates of strokes in "obese" women? I know of no study to quantify how many "obese" women have pre-existing diabetes, get pre-eclampsia, and then have a stroke, but the number is surely quite small, given the numbers in the Weiss study.  Yet this article makes it sound like it's a common occurrence.

Of course, the ironic thing is that she's not even very large to begin with.  Near delivery she was 261 pounds, but most of that was edema, a common byproduct of pre-eclampsia.  Before pregnancy she was only 195 pounds. I'm considerably larger than her; if weight causes diabetes, why didn't I have pre-existing diabetes plus kidney damage before pregnancy?

Rather than the problem being from her weight itself, likely there is something metabolic going on.  She mentions that she is the smallest one in her family; her brother weighed more than 700 lbs before having a gastric bypass.  To have a sibling be that supersized and to have yourself have diabetes badly enough to have developed significant kidney damage by age 38 means that something else is going on, likely something metabolic.  This is not just someone who "can't control themselves" but rather someone who likely has a lot of genetic and metabolic blocks stacked against her. It doesn't mean that all fat women of her size are facing a similar level of risk. 

My heart truly goes out to this woman and all she has been through.....but especially because of all the guilt they have laid on her about her weight "causing" this complication.  She has enough to deal with already.

Of course, the article ends with the mother pledging to lose weight and reform so she can see her baby graduate from college:
Voila.....bad mother becomes good mother by pledging to buckle under and toe the line. Cue the violins....even though there is no way to know whether going on a "strict, strict, strict diet" would have prevented this from happening, will prevent future complications, or will instead just result in yet another yo-yo that will end with her being fatter than she even started. 

I'm going on a strict, strict, strict diet," she said.  "I'm not going through this again.

It's not that we should never discuss worst-case scenarios; some fat women do experience major complications and their stories deserve to be told.  The problem is that the worst-case scenarios are presented in these articles as if they are a commonplace occurrence, as if that level of complication is common to most fat women......and it's not. 

And NONE of these articles ever tell the story of fat women who experience healthy, normal pregnancies, when that is actually a more common story. 

It's the lack of balance in these stories that is so bothersome.

Ulterior Motives

Underneath all of this lies the real purpose of the article.....to promote bariatric obstetrics. It's subtle, but if you read carefully there is hint of an underlying agenda in the article. 

Re-read the article again and notice how prominently the article emphasizes what a terrible burden obesity is on neighborhood hospitals, how they are having to buy all this specialized equipment for all these fat people, and how much Ms. Garcia's medical bills cost, etc. 

Then notice how it conveniently mentions that a bunch of hospitals in the NYC area are considering banding together to provide a specialized clinic for obese clients.  As the article says:

One possibility is to create specialized centers for obese women.  The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean ssections and intensive care for newborns, said Dr. Adam P. Buckley, an obstetrician and patient safety expert at Beth Israel Hospital North who is leading the group. 

The idea of a centralized clinic to deal with the specialized needs of "obese" women is not a brand new one; several places around the country (and world) already do this.  But it is a trendy one, and one with powerful economic incentives.

The advantages of specialized centers is that only one place has to buy the specialized equipment that may be needed for supersized clients.....larger BP cuffs, longer anesthesia needles, sturdier tables, etc.  Since getting doctors and hospitals to supply and regularly use large BP cuffs etc. can be a problem, this might actually have some benefits.  But really, don't these hospitals also serve fat non-pregnant people?  Shouldn't they be stocking larger equipment anyhow?  Or are we going to start centralizing care for all fat people next?

The problem with the idea of centralized care is that it ghettoizes fat pregnant women, as we've discussed before.  It creates a climate rife for over-intervention, with little questioning about whether the interventions are prudent or even necessary.  It applies the "super high risk" label to all fat pregnant women, whether or not they actually experience complications, and subjects them to extreme amounts of intervention they may not need.

The induction and c-section rate in a bariatrics obstetrics specialty is likely to be even more astronomically high, because the doctors automatically see the obese woman as super high-risk.  And it's likely that the fat women at these centers will not be offered access to midwifery care, waterbirth, positioning options, or choices that can help lower the rate of sections and complications instead of adding to them. 

Historically, little good has come from classifying various pregnant populations as high-risk and treating them as such before any such complication occurs.  All that really happens is that more women undergo risky inductions and planned cesareans, and their infants experience higher levels of interventions that interfere with breastfeeding and bonding.  The high-risk label often leads to increased intervention without improvement in outcomes, and this is likely true also for women of size.

Furthermore, postpartum interventions will no doubt also include being bullied even more strongly than usual about nutrition and weight loss, and there will probably be a lot of gastric bypasses coming out of these programs, another financial boon for the hospitals.

Before such bariatric obstetrics centers are embraced across the country, they need to prove that their high-tech, high-intervention approach actually improves outcomes.  The cesarean rate should be lower in such bariatric centers, the fetal outcomes should be better, and they should have a high rate of long-term weight loss success.  But nowhere is there any research proving any such thing.  Instead these centers are allowed to open and operate without any closer review, and their intervention rates are allowed to go unchecked and unreviewed.

Another even more compelling issue is that the right to self-determination of care will be taken away from fat mothers if they are forced into these "obesity ghettos."  As long as the baby is healthy and there are no major complications, fat women should have the right to choose the style of care they want, the amount of intervention they prefer to use, and the way they want to give birth, just like any other woman does. 

If they want the high-risk ticket, they should be able to choose that.  But if they have little or no complications, are otherwise low-risk, and want alternative options like midwives or waterbirth, they should have the right to determine that for themselves, not be forced or scared into the Fat Farm Chophouse.

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

Apparently, all it takes is extra pounds.

Summary

It's not that the possible risks of "obesity" and pregnancy should never be discussed with women of size.  Of course they should.  Women deserve to be informed of the possible risks.

However, this article was full of distortions and worst-case scenarios, and it implied that experiences such as stroke during pregnancy are extremely common in fat women.

Anyone reading these types of articles might well conclude that virtually no fat woman has ever had a healthy pregnancy or a healthy baby, that the only way to have a healthy pregnancy is to lose vast quantities of weight first, and that the vast majority of fat women experience major complications and have unhealthy babies. And that simply doesn't jibe with the experiences of most fat mothers.

Yes, women of size are at increased risk of some complications. But the article distorts the magnitude of that risk and presents weight loss and highly interventive care as the only paths to a healthy pregnancy.

In fact, many women of size have healthy pregnancies and healthy births.....you can read many of these stories on my website.  I was one of them. I somehow managed to have four healthy babies at a much higher starting weight than the woman in the article. Despite being larger than her, I never had diabetes, I never had pre-eclampsia, I never had kidney problems, and I never had a stroke. And I know many more fat women just like me, in all sizes of fatness, who had healthy pregnancies and babies, in all sizes of fat. But THAT part of the obesity story doesn't get publicized.

It's not that you cannot discuss the possible risks of obesity in pregnancy with women. But it needs to be done in a fair and balanced way. This article was not well-balanced, it didn't discuss the possible risks in a reasoned and calm manner, nor did it acknolwedge that many women of size can have healthy pregnancies and babies.

Sensationalistic articles like this are done to shame and scare women out of pregnancy, or into compliance with draconian interventions like weight loss surgery, lack of weight gain during pregnancy, extreme prenatal testing, unnecessary inductions, or planned cesareans.  Postpartum, they try to shame women into emphasizing weight loss at any cost, despite the fact that long-term research shows that nearly all diets will fail, many of the women with weight loss surgery will experience nutritional complications, and that weight loss attempts are one of the major factors in weight gain over the long run. Approaches like this will likely just worsen the problem, not improve it.

Furthermore, while I'm sure some of these doctors have good intentions towards helping women of size, there is an undertone of economic incentives here that is being ignored. 

By exaggerating the risks of obesity in pregnancy, doctors, hospitals, and insurance companies can push for centralized services that cater primarily to "obese" women, and bill for more services and interventions because these women are "so high risk."  This"bariatric obstetrics" approach is a tremendous potential cash cow for providers, and it's no coincidence this article appeared in the Times just as the hospitals there are considering creating a centralized treatment clinic.  This article was not meant just to inform but also to market the new profitable field of bariatric obstetrics to other doctors and to obese women themselves.

Although there can be advantages to centralized facilities for women who experience major complications, fat women with healthy pregnancies should not be forced into these facilities to receive care. It is wrong to imply that all fat women are at the same level of risk as the woman in this story, or that we all require such specialized care. Many of us actually do better in low-tech, low-intervention care.

Yet more and more I am hearing from fat women who are being DENIED the opportunity for homebirth, birth center birth, or a VBAC trial of labor, simply because of weight, regardless of actual health or complications. I am hearing from women of size who are being REQUIRED to go to these bariatric obstetrics hospitals where they are not given access to midwives or low-tech/alternative options. Their rights and choices are being taken away from them, simply because they are fat and perceived as ultra high-risk.

Being fat does not mean your right to choose your own preferred style of care is forfeit. Right to bodily autonomy is everyone's right, regardless of fatness. But by exaggerating the risks of obesity and concentrating on the worst-case scenario stories, the authorities try to make a case for taking away just that.

No, we don't have to ignore potential risks, and information about proactive ways to lessen risk can be helpful.  But stop the hyperbole about risk, stop treating obesity so simplistically, stop using only worst-case scenario stories in these articles, and stop trying to create a new profit margin by ghettoizing fat women and exploiting them for profit.

P.S. I hope other fatosphere bloggers and birth bloggers will dissect the Times article and blog about its  weaknesses.  I should not be the only one blogging about this issue, and we need a greater chorus of voices protesting such articles out there.

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.

The Patient's Best Interests? Not Anymore

Check out Rixa's recent interview with Dr. Stuart Fischbein, a VBAC- and breech-supportive doctor in California who is in trouble with his hospital for supporting Vaginal Birth After Cesarean (VBAC) and vaginal breech births.

It's an interesting summary of the sad state of birth in hospitals these days.....ruled not by the patient's best interests, but by the hospital's best interests, along with doctor convenience, insurance rules, ease of staffing, and fear of litigation.

As a feminist, I am particularly upset at how a woman's right to decision-making about her own health, her own body, and her baby is currently being taken away from her. And yet there is a stunning lack of recognition or caring about this fact in our society.

Dr. Fischbein at least is talking about this issue. He recognizes the tension between hospital concerns and patients' rights as one of the major ethical dilemmas of our time.

He has some interesting and frustrating things to say about hospital and insurance decision-making. He also discusses home birth, the midwifery model of care, tort reform, malpractice and litigation, among many other things.

I don't agree with everything he says but overall it's a very interesting interview with many important points. And it's so refreshing to hear of a doctor who is actually fighting for the patient's interests (not just his own or the hospitals' interests), and who is trying to stand up for the patient's right to make her own medical decisions.

Here are a few excerpts, edited for clarity, length, and sometimes rearranged a bit from the original.

On the Use of Certified Nurse-Midwives (CNMs) in the hospital:

About 5-7 years into my practice...I was approached by a couple of midwives and a good friend about opening a collaborative midwifery practice with hospital deliveries. We looked for a hospital on the west side of Los Angeles that would allow midwives to do deliveries and we couldn’t find one. None of them were allowing midwives to do deliveries...So we opened a practice out in Ventura County and called it the Woman’s Place for Health.

Even there we were met with a lot of suspicion and resistance, despite the fact that the track record for midwives is excellent, despite the fact that they take care of low-risk patients and have very strict protocols that they follow, despite the fact that they have excellent outcomes and a very low c-section rate, even compared to other obstetrical models that take care of low-risk patients. It’s always been a battle.

...We follow the midwifery model of care, which exhibits a lot more patience than the obstetrical model of care. It treats pregnancy as a normal function of the body. In contrast, the obstetric model treats pregnancy as a disease that needs to be treated, as opposed to something that just needs to be nurtured.

About VBACs and Patient Rights:

If you go on [ACOG's] website—the back part, where members can go—they have paragraph after paragraph about patient’s rights, patient’s autonomy, the right to informed consent and refusal, the right not to be harassed or threatened if they make a decision that is different from what the hospital would want, the right to sanctity of their bodies free from fear of reprisals.

...The problem with VBAC bans is that it puts the needs of the hospital and the other health care workers ahead of the rights of the patient.

I understand why they do that, but I just think they are misguided. They ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections...so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.”

But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.

On the Lack of Truly Informed Consent:

There’s a study that came out in the American Journal of Obstetrics & Gynecology last December that found the morbidity of a repeat cesarean section is higher than a successful VBAC.

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth. That’s outrageous to me. It leaves me speechless, and for me that’s no small thing!

The same model applies to breech deliveries. Some women are being told to have a procedure that carries more morbidity than a vaginal delivery. But they are never being told the numbers or given the option.

About Why Many Hospitals Ban VBACs:

The reason that a lot of hospitals ban VBACs anyway—and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety.

The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Again, they use the idea of the 24-hour anesthesia as a reason not to allow VBACs. Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture. They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations. And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs? If they can’t do VBACs, should they be doing obstetrics at all?

On Vaginal Breech Birth:

Decisions for breech delivery should be based on the experience of the practitioner and the desire of the patient.

I understand that breech delivery is not for everybody. Certainly there are a lot of people who will never do breech deliveries because they’re not trained any more. Unless we bring vaginal breech delivery back into residency training programs, we will soon find that that skill is gone forever.

Having that skill gone is more than just a c-section problem. Every now and then, a woman is going to show up in labor, come in completely dilated with a butt in the vagina, and no one is going to know what to do...They’re going to be rushing to push the baby’s body back up and do a c-section. Quite frankly, the morbidity of that is so much higher. So it is going to be a major loss, because women are going to show up complete and breech in labor & delivery, and no one is going to know what to do.

In Canada, the SOGC is no longer recommending routine c-section for breech babies. Part of it’s for cost savings, probably. But part of it is because the evidence does not support sectioning every breech patient. The evidence is there to give patients the choice. This gets back to my primary issue, which is informed consent. This should not be a decision where the doctor tells the patient what to do.

If the doctor does not know how to do breeches, they should say to the patient “I can’t do your breech delivery but I really think you are a good candidate for it. Why don’t you see doctor X for a second opinion.” That’s the honorable thing to do. But of course that would cost doctors money, and a lot of doctors don’t want to give up the money.

On the Lack of Attention to Birth Politics:

I don’t know why maternity issues like these are not more popular, because every family in America is affected by what’s going on. It’s off the radar screen.We have an abortion rights movement in this country that, the minute anything happens regarding abortion, they’re up in arms about it. Yet women are losing the choice of how they give birth, and no one seems to care.

There's much more to the interview; I hope you will go check out the whole thing. You can read it at Rixa's Stand and Deliver blog:

http://rixarixa.blogspot.com/2009/08/interview-with-dr-stuart-j-fischbein.html