Belly Blog Carnival!

The beauty of my body isn't measured by the size of the clothes it can fit into, but by the stories it tells. I have a belly and hips that say, 'we grew a child in here' and breasts that say, 'we nourished life.'

- Sarah from I Am Beautiful: A Story of Women in Their Own Words

A while ago I called for a Belly Blog Carnival, to counter the lack of pictures in our society of pregnant women of size, as a way for us to work through our various feelings about how pregnancy affects our bodies....and yet still honor our bellies for the amazing work they have done.

I am thrilled to say a number of people submitted pictures, blog entries, or both.  Because there were a number of submissions, I've divided them up into different posts.

This post is to list all the blog entries with people discussing their feelings about their pregnancy bellies.  I'll have another post soon with just pictures of those that had specific timelines and gestational ages, and others with just general pictures. I also have a couple of posts already up or coming soon about how women can honor and celebrate their bellies even more during pregnancy.

So without further ado, here are some of the posts people submitted for inclusion.  For those sensitive to these things, do note that some have trigger warnings for frank discussions of body ambivalence.  Some people might find that distressing, but personally I find it refreshing to have such honesty about struggles we all have had sooner or later about body image. I would remind people that such reflection, both negative and positive, is a big part of how we progress further on our journey to self-love and body acceptance.  See these musings as part of our journey of healing and self-acceptance.

Cassandra, a.k.a. Metaphysical Mama at http://thelogicallady.blogspot.com/, wrote very frankly about her struggles with self-esteem and body image as she went through pregnancy and post-partum.  However, she ends on a very positive note, noting:

Like life in general, learning to love a body that most of society says isn't worthy of it is a long road full of set backs. I've been apart of the fat acceptance community since 2005 and obviously I still have a lot of issues to work through. Being pregnant opened my eyes to just how much work I have yet to do still, but also gave me a new found appreciation of the amazing things it is capable of, things most of society says it shouldn't be able to do or shouldn't be able to do as easily as I did. And, I really love that.

Arwen Spor of http://desertspor.blogspot.com/ submitted "Stretched Out," some musings at seeing herself in the mirror at 8.5 months pregnant.  The good news is that her baby has since been born, all 11+ pounds of him!  (And yes, she birthed him vaginally.)  About an earlier birth, she wrote: 

I know now why many women refer to natural birth as “empowering.” It was amazing how my body knew what to do at every point in the birth process. I did not need anyone this time telling me what was happening or how to push or anything else. I could feel it. It was amazing. And I will hold onto that for the rest of my life. 

Parker at http://ourmonsterlife.blogspot.com/ wrote frankly about her thoughts and worries about her weight and size during and after pregnancy and how it affected her body image, both negatively and positively. You can read about it at A Belly Story: Body Issues During Pregnancy and Postpartum. I really appreciated her honesty and her courage in sharing both pictures of her pregnant belly and her postpartum belly, which you see here.  She wrote:

The postpartum period is such a weird place to be in regards to body identity. Your body was just ballooned to proportions you never thought possible, and suddenly it's gone...Truthfully, just short of 5 months postpartum at 195 lbs, some days I look at myself and I think, "Not bad! Not bad at all! Could definitely be worse!" and some days I am really disappointed by the fact that I still can't fit into the clothes I want to wear. But when I look at my body, I don't hate it. I'm not disgusted. ...Being pregnant and giving birth has brought me to a point of a kind of bittersweet acceptance with my body. My breasts may be different, but I am proud of the fact that they make milk and have been my daughter's sole source of nourishment for her entire life. My body makes her food. That's amazing! Sure, my tummy has a bulge that wasn't as big before, it has stretch marks that weren't there before...but I'm proud of the fact that a life grew in there. A whole person was created inside my belly. I mean, that is EPIC! I gave birth!!  So, do I like how my body looks? On a purely shallow level, I'm not ecstatic about it in and of itself, but I'm definitely okay with it. The strange and wonderful thing is... I love my body anyway. I wish I could high five it. So what if I wear size 17 pants? My body is beautiful to me just the way it is because I am a mother.

One of my favorite birth people, Lexi of http://birthislife.blogspot.com/, wrote about her struggles with body acceptance too.  She discussed how she knows her body has done amazing things, but she often doesn't honor or respect it enough for what it is capable of.  However, she took a moment at the end to honor and love her body, "flaws" and all.  She wrote:

Women's bodies are changed by childbirth. Long ago and far away that was revered. Saggy breasts, full bellies and wide hips were normal and expected. They're still normal, yet seem very unexpected. We live in a world where our self esteem is determined by how soon after birth we can squeeze into our skinny jeans, rather than being cherished for who we are and what we do. That world inside our own head, where we are meaner to ourselves than we would ever allow anyone else to be to us. So, at least for today, I am celebrating my body and my belly for all it has done for me. I accept all of it, the way it is - the way I am. At least for today, I choose to see my stretch marks as signs of the life I carried within me, my scar as evidence of my love for my children. Body, at least for today, I love you!

Issa of http://lovelivegrow.com/ submitted "Big Bare Beautiful Baby Belly," with lots of absolutely gorgeous naked pictures of her baby belly.  Issa is due with her baby shortly but her pictures were taken at about 33 weeks.  She said:

While I’ve spent a lot of my life really concerned about my size, unhappy with my body, and desperate to change it, over the last two or three years I’ve completely gotten over that. I’m really glad that I made that mental shift prior to getting pregnant. So many women, fat or otherwise, feel insecure about their growing pregnant bodies, and I’m glad that hasn’t been a factor for me...In any case, for all the complaining I’ve had this pregnancy...the growing size of my body isn’t one of my complaints. It’s actually probably my favorite thing. I simply love my big beautiful baby belly!

Thank you to all the people who submitted pictures, blog musings, and stories.  It was wonderful and inspiring to go through them all, and I hope it will be inspiring to others who are just starting on this journey. And what better day to publish them than today, on Mother's Day?

Remember, it's normal to be challenged by your feelings as your body grows in pregnancy, and it's normal to feel ambivalent about these changes in your body, especially once the baby is born.  Every woman feels this ambivalence, but it can be even more intense in those of us who have struggled with body image issues because of society's biases around weight.  It's normal, but it's helpful to see it merely as part of the ongoing process of coming to peace with your body. 

Remember, your body has done AMAZING things. It grew a HUMAN BEING inside!! It deserves so much credit for this amazing miracle. 

Of course it's going to be changed by such a momentous process! How could anyone expect otherwise? 

But while it's normal to have mixed feelings about these changes, take time also to HONOR YOUR BODY for the work it has done and for the wondrous miracle it has produced. 

Happy Mother's Day, everyone.

Honoring Our Bellies: Belly Henna

May is Honoring Our Bellies Month at Well-Rounded Mama!

During this month, we will be blogging about pregnancy bellies in women of size, honoring the work our pregnant bellies have done, and showing the diversity of pregnant bellies in women of size.

Today we talk about Belly Henna.

One of the more fun things some women are doing to celebrate their pregnant bellies is decorating them with henna art.

Above is the henna tattoo of a dear birth-world friend of mine, also a woman of size, from her Blessingway. 

Isn't it lovely? 

This is one idea I never got to use during my pregnancies and now I wish I had!  We did belly painting with my kids, but of course it wasn't as lovely as this.  This is just too cool!

For those who are not familiar with them, henna tattoos are temporary.  They get painted on with a special paste, made with henna.  At first it looks dark, like this.

In time, the henna paste rubs off and a temporary light-orange-to-golden stain is left on the skin, like this.

The stain (known as "mehndi") on the skin will go away in a few days to a couple of weeks in most people. It's often done on the hands and feet as well.

The intent of doing henna art in pregnancy was originally to protect the child.  Quoting from the Henna Caravan website:

Lawsonia Inermis or henna is a small bush that produces a red dye that has been used cosmetically and medicinally for over 9,000 years. Many countries including Morocco and India have traditions of applying henna during the third trimester of pregnancy. Henna is believed to protect and bless the mother and child from any evil or malicious spirits that may be near during delivery. The red coloring of the dye and protective images used in the patterns guard against the evil eye and are thought to protect the pair during the child's difficult passage into this world.

Here's how getting a henna tattoo works.

Henna powder (ground from the dried leaves of the henna plant) is combined with lemon juice, sugar, and essential oils (like lavender) and made into a paste, then applied onto the skin in decorative patterns.  The paste must be left on for several hours. 

At some point after the paste is dry, most henna artists have you come back to "seal" the design by applying lemon sugar syrup, pump spray hair gel, or liquid bandage, etc. The longer the paste can be kept on, the better the tattoo.  Eventually, however, the paste rubs off, leaving the "tattoo" behind.

There are a few precautions to be aware of.  You want to make sure your artist uses only benign ingredients; occasionally some artists add unsafe chemicals or use "black" henna (which is really PPD, para-phenylendiamin, a.k.a. black hair dye) instead of true henna.  These can cause blistering or other problems.  Always ask the artist what is used in their henna paste before agreeing to a tattoo.

According to some websites, henna artwork should be avoided in women who are extremely anemic or women whose babies have G6PD deficiency or hyperbilirubinemia. Any woman who has had (or who has had a child who has had) a chronic or acute condition affecting the blood system or immune system should also not receive henna.  Other than that, though, belly art with henna is thought to be a very low-risk decorative option.

I've had henna done on my hands in recent years, but seeing how lovely these henna tattoos came out, I sure wish I'd known about it during my childbearing years!  Way cool. Would have been fun during a blessingway ceremony.
 
Just another way you can celebrate your belly and your baby during pregnancy!!  (And who's to say it has to be limited only to pregnancy!)

*Thanks to Angela and Stacy, both women of size, for sharing their henna pictures with us.



Here are some more links about henna for pregnant bellies:

http://www.hennacaravan.com/pregnancy.html - general information about henna in pregnancy
http://www.shophenna.com/GalleryBelly.htm - pictures of various belly henna designs
http://www.hennapage.com/henna/what/freebooks/HPJpp2.pdf - e-book about henna traditions postpartum
http://www.hennapage.com/henna/encyclopedia/pregbirth/index.html - info and pictures
http://www.castingkeepsakes.com/pregnancy-henna-art-kit-p-217.html - a kit you can order
http://www.icnha.org - organization of certified henna artists
http://www.hennapage.com/  - information about henna use in general
http://hennadenver.com/henna-faq/ - info about henna for pregnancy

Bigger Dose of Antibiotics Needed For Women of Size?

It's time to finish our focus this Cesarean Awareness Month on the over-utilization of cesareans in women of size and the burdens this high rate imposes on this group.

Consider a new study just out that suggests that women of size might benefit from a bigger dose of antibiotics if they undergo a cesarean. 

This further supports the idea of the importance of weight-based dosing of certain types of antibiotics when people of size undergo other surgeries as well. 

Wound infection is a very significant risk of cesarean sections in women of size, especially "morbidly obese" women.  Part of the reason for this is that adipose tissue tends to be poorly vascularized and oxygenated, which makes it harder for that area to heal as effectively.

However, another reason for a higher infection risk may be that "obese" women are being under-dosed with antibiotics when standardized dosing (the same for all weights) is used instead of weight-based dosing. 

In this new study, the same standardized antibiotic regime was given to all women (regardless of size) undergoing a planned cesarean delivery.  Women were categorized by BMI, and then tested to see how well the dosage was working at different times during the delivery (incision time, closure time). 

The antibiotic dosage was fine for everyone for gram-positive bacteria, but the story was considerably different for gram-negative bacteria.

One-third of the "extremely obese" women (BMI greater than 40 in this study) did not achieve minimal inhibitory concentrations at skin incision, and 44% did not achieve minimal inhibitory concentrations at closure. 

So by the end of the surgery, nearly HALF of the women with BMI greater than 40 did not have enough concentration of antibiotics in their tissue to effectively ward off a gram-negative infection. 

Reflections on the Study

For years, doctors have blamed all kinds of factors for the higher rate of wound infection in fat women. And to be fair, many of these factors are relevant.

However, this study shows it's likely that fat women also have higher rates of wound infections because their doctors are inadvertently underdosing them with antibiotics.

We in the fat acceptance community have been telling them this for years, but on the whole doctors have been very slow to listen and heed our feedback. Why has it taken the medical community so long to listen?  Will this study finally change the standard of care? 

Only time will tell...but I'm not holding my breath.  In the meantime, in light of just how high the cesarean rate (both planned and unplanned) is among women of size in the USA....consider the implications of such an excessive cesarean rate for infectious burden, healthcare costs, and disruptions to the mother's life just as she is trying to bond with her newborn.

The lessons from this study are twofold. 

First, for when a "morbidly obese" mother truly needs a cesarean, doctors should explore weight-based dosing with certain types of antibiotics, and then study this practice to see if this lessens the risk of infection. 

Second, because the risk for infection/wound complications is increased in "morbidly obese" women, doctors should stop doing things that increase the cesarean rate in this group.  For example, doctors need to stop scheduling this group for routine "elective" cesareans, and stop practices (like induction for suspected "big baby") that increase the risk for cesarean during labor. 

The medical, financial, and personal burdens that result from infections and wound complications after cesarean are clear. 

Stop placing fat women at increased risk of these burdensome complications by over-utilizing cesareans and inductions in this group.



Study Abstract

Pevzner L, Swank M, Krepel C, Wing DA, Chan K, Edmiston CE Jr. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery.  Obstet Gynecol. 2011 Apr;117(4):877-82.

From the Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California; Surgical Microbiology Research Laboratory, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; and the Department of Obstetrics and Gynecology, Long Beach Memorial Medical Center, Long Beach, California.

Abstract

OBJECTIVE:  To estimate the adequacy of antimicrobial activity of preoperative antibiotics at the time of cesarean delivery as a function of maternal obesity.

METHODS:  Twenty-nine patients scheduled for cesarean delivery were stratified according to body mass index (BMI) category, with 10 study participants classified as lean (BMI less than 30), 10 as obese (BMI 30-39.9), and nine as extremely obese (BMI 40 or higher). All patients were given a dose of 2 g cefazolin 30-60 minutes before skin incision. Antibiotic concentrations from adipose samples, collected after skin incision and before skin closure, along with myometrial and serum samples, were analyzed with microbiological agar diffusion assay.

RESULTS:  Cefazolin concentrations within adipose tissue obtained at skin incision were inversely proportional to maternal BMI (r=-0.67, P less than .001). The mean adipose concentration was 9.4 plus or minus 2.7 micrograms/g in the lean group of women compared with 6.4 plus or minus 2.3 micrograms/g in the obese group (P=.009) and 4.4 plus or minus 1.2 micrograms/g in the extremely obese group (P less than .001).

Although all specimens demonstrated therapeutic cefazolin levels for gram-positive cocci (greater than 1 microgram/g), a considerable portion of obese and extremely obese did not achieve minimal inhibitory concentrations of greater than 4 micrograms/g for Gram-negative rods in adipose samples at skin incision (20% and 33.3%, respectively) or closure (20.0% and 44.4%, respectively).

No significant difference in cefazolin concentration was observed in mean closure adipose, myometrial, or serum specimens across the BMI categories.

CONCLUSION:  Pharmacokinetic analysis suggests that present antibiotic prophylaxis dosing may fail to provide adequate antimicrobial coverage in obese patients during cesarean delivery.

PMID: 21422859

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

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

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

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

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

Increased Anesthesia Complications

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

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

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

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

And still, 1 in 12 had anesthesia complications.

High Rate of Wound Complications

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

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

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

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

Summary

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

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

This practice has to change.

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

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

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



References

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

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

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

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

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

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

Routine Cesareans Not Better for "Extreme Obesity"

If you are a "supersized" woman, many doctors won't even give you a chance anymore for a vaginal birth. 

They often argue that a cesarean delivery is better and safer in women with "extreme obesity."  They argue that it is unlikely that a woman that fat will be able to deliver vaginally, and even if they did, the baby is likely to be harmed via hypoxia or birth injuries. They also argue that if a cesarean during labor were needed emergently, doing one on someone of that size would lead to poorer outcomes because of the delay that could be encountered in getting to the baby. So many doctors contend that it's just better to plan an "elective" cesarean with women of that size.

However, little research exists to support this idea. Instead, doctors are relying on their biases and their fears when making the decision about planned vaginal vs. planned cesarean births in this group.  The bottom line is that most don't believe that "extremely obese" women CAN birth vaginally, that vaginal birth in fat women is extremely dangerous when it does happen........so a planned cesarean is assumed to be safer for this group.

A new study finally questions this assumption and actually collects data on this issue. 

It showed that a policy of routine cesarean delivery in supersized women does NOT improve outcomes, and that most women with "extreme obesity" can birth vaginally.  It concludes that decisions about planned cesareans in very fat women should be made on an individual circumstances, just as it is with other women. 

Study Details

This is a very strong study, done nationwide in the UK as part of their National Health Service (NHS).  You need that kind of nationwide study because there usually aren't all that many women with BMI greater than 50 (the definition of "extreme obesity" in this study) in any one hospital or even any one region.  In order to have robust findings, you need data from a large group of hospitals, with a large sample of women who fit the study's parameters. Even in a nationwide study like this, the study group size was only 591, but that's as robust a study group as you are likely to get in research on this population.

Of the 591 women with BMI greater than 50, 174 had a planned cesarean, compared to 417 who were in the planned vaginal delivery group.  The study then tracked the outcomes of each group.

[It's damning with faint praise to have to say this, frankly, but lukewarm kudos to the NHS for planning a vaginal delivery for most (70%) of these "extremely obese" women ─ this wouldn't happen in many areas of the USA.  The trend here is simply to automatically schedule most supersized women for a cesarean.]

Considerably warmer kudos to the NHS for the fact that of those supersized women who planned a vaginal delivery, 70% actually achieved a vaginal delivery. 

Yes, you read that correctly.  70%, or nearly 3 in 4 of women with a BMI greater than 50, actually had a vaginal birth when given the chance to labor.

This is extremely different than what most doctors believe about a "morbidly obese" woman's ability to give birth vaginally. And I'd bet good money that the UK's vaginal birth rate in this group could be even better if they induced less.

Even so, that's far better than the US rates. Compare the NHS's 30% c-section rate in women with BMI over 50 to US studies. For example, Weiss (2004) and Dietz (2005), both very large, multi-hospital studies in the USA, found a nearly 50% c-section rate in women  with BMI greater than 35 ─ in first-time mothers!

Do you really think that the uteri of British women are that much more efficient?  A ~20% lower c-section rate, despite a BMI starting more than 15 points higher? 

Doctors like to assume that cesarean rates in morbidly obese women are due solely to maternal factors, like "poor contractility" or "soft tissue dystocia" (a.k.a. fat vaginas). 

But obviously, physician management has much more to do with cesarean rates in very fat women, or the cesarean rate in high-BMI women would be consistent between countries and over time. 

Nitpicks About The Study

Overall, it's a pretty decent study, but I would nitpick a few things.

First of all, their multivariate model of risk factors for cesarean in labor did not even address induction (!), which is probably one of the biggest drivers of a high c-section rate in women, let alone women of size.  Study after study shows an extremely high rate of inductions in women of size, yet rarely do studies control for this factor.  Connect the dots, people!  (More on this below.)

The study could also have used a lot more information on how the labors of "extremely obese" women were managed, especially in comparison with the labors of non-obese women.  Furthermore, it might have been quite illuminating to compare the labors and physician management of those high-BMI women who ended up with a cesarean after labor to those who ended up with a vaginal birth.  Why aren't we evaluating and discussing how to improve vaginal birth rates in high-BMI women instead of just clutching our pearls and lamenting cesarean rates in this group?

Don't get me wrong; the study was ground-breaking and pretty amazing for the generally fat-phobic world of obstetrics.  But I wish they would go beyond the simplistic and get into more substantial evaluation of the deeper questions these studies bring up.

The main negative finding in the study was the fact that the "extremely obese" women in the vaginal birth group had a shoulder dystocia rate of 3.1%, which is higher than the rate reported in an unselected population (0.6%).  Fear of shoulder dystocia and related birth injuries causes many doctors to promote planned cesareans for women of size, but it's important to note that NONE of the babies involved experienced permanent injury so the finding is of questionable importance.  Also, some studies that control for fetal size and diabetic status have found that once these are accounted for, obesity is not associated with shoulder dystocia. So it's ridiculous to mandate a cesarean for supersized women simply out of fear of shoulder dystocia and birth injuries.

Furthermore, if they wanted to reduce the shoulder dystocia rate in this group, I bet they could do so by "allowing" them more mobility during labor, encouraging alternative positioning instead of the "stranded beetle" position, inducing less often, discouraging early epidural placement, and avoiding forceps/vacuum extraction more often.

The answer to shoulder dystocia concerns is not more cesareans, but rather exploring preventive management during labor and improving SD management if it does occur.

Another negative finding in the study is that almost no supersized women tried for for a VBAC, and of the few who did, the success rate was very low (9 of 26, or 35%).  The study notes that the VBAC rate in some studies is low in women of size, implying that there is little reason to allow a trial of labor in this group. However, they fail to note that these studies have extremely high rates of induction, which is known to lower the VBAC success rate substantially, nor did they note how many of the women in this study were induced in their attemtped VBAC. We have yet to have a really good-quality study of VBAC in "morbidly obese" women, one in which these women were given a reasonable chance at VBAC with a spontaneous trial of labor.  It is FAR too soon to be making sweeping judgments about who should and should not be "allowed" a trial of labor.

The lack of recognition of the negative role that induction plays in the birth outcomes of high-BMI women is tremendously frustrating to me and remains one of my pet peeves in this type of research. Even this study ignores it.  Sigh.

On a happier note, one positive finding was that the study did not find any statistically significant differences in anesthetic, maternal or neonatal complications between the planned vaginal and planned cesarean groups, except the occurrence of shoulder dystocia (again, none of whom experienced permanent injury).  This belies the common perception that outcomes are poorer when vaginal delivery is "allowed" in supersized women. 

It's important to note that the rate of composite major maternal morbidity was higher in the planned cesarean group (6.3% vs. 4.3%), but alas, the difference did not rise to statistical significance.  With a larger study, chances are it would have.

Cesareans are an important risk factor for hemorrhage, blood clots, infection, wound comlications, and admission to Intensive Care, especially in this group.  Therefore, it's indefensible to automatically expose supersized women to these complications across the board, based on their weight alone.

Conclusions

Finally, the commentary by S Quenby that accompanied this study was interesting. 

A consequence of this data [about complications among obese women] is the frequently voiced opinion at midwifery, obstetric and anaesthetic conferences that the safest way to deliver a women with a body mass index (BMI) over 50 kg/m2 may be by elective CS. This elective option has been proposed as a way of avoiding the known risks of vaginal delivery and emergency CS in this population.

[This study] challenge[s] the assumption that elective CS is safer than planned vaginal delivery in these morbidly obese women. A large proportion, 70% of women with BMI [greater than] 50 kg/m2, who had a planned vaginal delivery did indeed deliver vaginally without the expected increase in neonatal and postnatal complication rates compared with those with planned elective CS.

These data strongly indicate that elective CS in morbidly obese women cannot be justified, except for the usual obstetric indications. Only in very unusual circumstances should elective caesarean be performed if the requisite obstetric indications are not present.

Doctors need to STOP automatically scheduling cesareans for supersized women on the basis of their weight alone. 

Planned cesareans do NOT improve outcomes in this group, and there was a trend towards poorer outcomes with planned cesareans. 

Furthermore, contrary to what many doctors believe, this study shows that very fat women CAN give birth vaginally if given an adequate chance to do so.  It's about time we let them.

*Image above of obese cesarean from BMJ 2006 study on "Obesity and Reproduction," courtesy of Pubmed.


Study abstract

Homer CS, Kurinczuk JJ, Spark P, Brocklehurst P, Knight M.   Planned vaginal delivery or planned caesarean delivery in women with extreme obesity.  BJOG. 2011 Mar;118(4):480-7. doi: 10.1111/j.1471-0528.2010.02832.x. Epub 2011 Jan 18

National Perinatal Epidemiology Unit, University of Oxford, UK.

Abstract

OBJECTIVE: To compare the outcomes of planned vaginal versus planned caesarean delivery in a cohort of extremely obese women (body mass index ≥ 50 kg/m(2)).

DESIGN: A national cohort study using the UK Obstetric Surveillance System (UKOSS).

SETTING: All hospitals with consultant-led maternity units in the UK.

POPULATION: Five hundred and ninety-one extremely obese women delivering in the UK between September 2007 and August 2008.

METHODS: Prospective cohort identification through UKOSS routine monthly mailings.

MAIN OUTCOME MEASURES: Anaesthetic, postnatal and neonatal complication rates.

RESULTS: After adjustment, there were no significant differences in anaesthetic, postnatal or neonatal complications between women with planned vaginal delivery and planned caesarean delivery, with the exception of shoulder dystocia (3% versus 0%, P = 0.019). There were no significant differences in any outcomes in the subgroup of women who had no identified medical or antenatal complications.

CONCLUSIONS: This study does not provide evidence to support a routine policy of caesarean delivery for extremely obese women on the basis of concern about higher rates of delivery complications, but does support a policy of individualised decision-making on the mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes.

PMID: 21244616

A Peek Into The Future?

Here's an interesting little study with possibly big implications for the future. I haven't seen the full text yet, just the abstract, but I hope the study will generate some dialogue in the birth community during this Cesarean Awareness Month.

For years, birth activists have been decrying the increasing cesarean rate, while some doctors shrugged off the increase as unimportant. "A healthy baby is all that matters, and it doesn't matter how it gets here," is the refrain.

Yes, a healthy baby is always everyone's priority, but a healthy mama should be important too.  And generally speaking, a mama recovering from surgery is less healthy than a mama recovering from vaginal birth. And it's not just about the actual surgical recovery but also about the long-term complications that may ensue. As a result, more and more research is finding that a high cesarean rate has major public health implications.

This study uses computer modeling to predict just how high our cesarean rate may go in the future and what the implications will be for women's health. It predicts that the U.S. cesarean rate could top 55% by the year 2020 (which is not that far away!).

Now, I saw that and thought.....55% by 2020?  Really? The national rate is nearly 33% as of 2009, and they expect an increase of 20% more in just 11 years?  Seems like the prediction is a little excessive to me.  On the other hand, some hospitals in some areas of the country are already there.  If enough of them develop these outrageously excessive rates, who knows?

Currently, the cesarean rate is at or near 40% in some states. In the Miami area, the rate is around 50% already.  Twenty-four hospitals in California have rates between 40-50%, and five hospitals in California have rates already over 50%. At Kendall Regional Medical Center in Miami and in Corona Regional Medical Center in California, the cesarean rate is more than 70%.  What are the long-term implications for women in these areas?

It's very clear from research that cesareans increase the risk for placental complications in future pregnancies.  Conditions like placenta previa (a low-lying placenta, which can cause severe bleeding, prematurity, and death) and placenta accreta (where the placenta grows into the muscle of the uterus and sometimes even into the bladder or other structures near the uterus, which can cause catastrophic bleeding, hysterectomy, and death) will only increase as the cesarean rate goes up. 

We are already seeing increases in the rates of placenta previa and accreta due in large part to the rise in the cesarean rates. And rates seem to have a dose-response relationship ─ the more cesareans, the higher the risk for previa or accreta. 

For example, Clark (1985) found  that the risk of previa "increased almost linearly with the number of prior cesarean sections." They tracked the rates of previa by number of prior cesareans and found:

• 0.26% rate in an unscarred uterus
• 0.65% after one prior cesarean
• 1.8% after two prior cesareans
• 3.0% after three prior cesareans
• 10.0% after four, five, or six prior cesareans

Silver 2006 tracked the rates of accreta by number of prior cesareans and found:

• Placenta Accreta with second cesarean - 0.31%
• Placenta Accreta with third cesarean -     0.57%
• Placenta Accreta with fourth cesarean -   2.13%
• Placenta Accreta with fifth cesarean -      2.33%
• Placenta Accreta with sixth or more cs-   6.74%

The only reason we do not already have an epidemic of these complications is because most women have smaller family sizes now. The more cesareans a woman has, the more likely things like previa become. So the smaller family sizes of today has been somewhat protective...but is not enough.

Women who are having "only" their second or third cesarean are not safe from complications. Even just one cesarean increases your risk for placenta previa or abruption (tearing away of the placenta, which can kill the baby) next time.  Getahun (2006) found that the risk for previa in a second pregnancy after a first-pregnancy vaginal birth was 0.38%, but the risk was 0.63% if the first birth was by cesarean.  A similar increase in the risk for placental abruption was seen; there was a risk of 0.74% after a vaginal first birth, which increased to a risk of 0.95% after a cesarean first birth.

Although rarer in low-order cesareans, major complications can occur even after only 1 or 2 cesareans.  Fleisch 2007 is a case report of a 30-year-old woman, pregnant with her second child after one cesarean 2 years previously.  At only 20 weeks of pregnancy, she experienced a uterine rupture because of placenta percreta (an accreta that's grown into surrounding structures).  She lost her baby and her uterus.  She was lucky not to lose her life.  And there are other case reports similar to that one, too.

And although maternal death is a very rare outcome of cesareans, if you do enough cesareans, more women are going to die, as the study suggests.  Cesareans increase the rate of blood clots, which can be deadly, and hemorrhaging, which can be life-threatening if they can't stop it.  Anesthesia accidents, although very rare, do happen.  Do enough anesthesia, and even the less-risky regional anesthesia (epidural/spinal) cesareans will eventually cause some deaths.

And these are only the most serious of complications.  How many women will suffer the less lethal yet still serious complications?  Hysterectomy rates also increase significantly with each cesarean.  Infection is always a potential issue after any surgery, and especially so for women of size.  Internal scar tissue is extremely common after abdominal surgery, and it can cause great pain for some women, and even bowel and bladder complications years later.  Small bits of uterine lining can inadvertently be deposited outside the uterus and cause aggravating and painful endometriosis. The rate of tubal pregnancies and pregnancies in the scar goes up.  Fertility after a cesarean may decrease too. 

Of course, it's important not to panic. On an individual basis, the increase in cesarean rate is not that earth-shaking. Let me reassure you that if you personally have a cesarean, the odds are quite good that you will survive it and that you will recover just fine.  Although surgery is not the ideal way to start out your life as a parent, it obviously can be done, and many of us have indeed done it.  You'd get through it if you had to. A cesarean is not the end of the world, and it certainly doesn't mean you are any less of a mother or a woman if you have one.

But if you look at it from a public health point of view, the increase in cesareans has serious implications.  On a population-wide basis, a high cesarean rate means more women and babies will die, and even more will have other complications. The only thing that's kept it in relative check up till now is the smaller family size of most women these days.  But although the more serious complications tend to happen in those with multiple repeat cesareans, even women with only one or two cesareans are still at risk. Clearly, cesareans should only be done when the benefits outweigh the risks.

Even if you don't have children, never plan to have children, or don't care about whether people have cesareans or not, your health insurance costs will go up, just to pay for the complications that accompany a high cesarean rate. 

As a matter of public health, a high cesarean rate does matter, and we all need to care about it. 



Study Abstract

Solheim KN, Esakoff TF, Little SE, Cheng YW, Sparks TN, Caughey AB.  The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality.  J Matern Fetal Neonatal Med. 2011 Mar 7. [Epub ahead of print]

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA.

Objective. The overall annual incidence rate of caesarean delivery in the United Sates has been steadily rising since 1996, reaching 32.9% in 2009. Primary cesareans often lead to repeat cesareans, which may lead to placenta previa and placenta accreta. This study's goal was to forecast the effect of rising primary and secondary cesarean rates on annual incidence of placenta previa, placenta accreta, and maternal mortality.

Methods. A decision-analytic model was built using TreeAge Pro software to estimate the future annual incidence of placenta previa, placenta accreta, and maternal mortality using data on national birthing order trends and cesarean and vaginal birth after cesarean rates. Baseline assumptions were derived from the literature, including the likelihood of previa and accreta among women with multiple previous cesarean deliveries.

Results. If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually. The rise in these complications will lag behind the rise in cesareans by approximately 6 years.

Conclusions. If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

PMID: 21381881

New Facebook Resource for Big Moms

Good news!  Some friends of mine from the birth and Fat-Acceptance worlds just created a Facebook page for moms of size.   It can be found at:

http://www.facebook.com/pages/The-Ample-Mother/196081560418122

The idea behind the Facebook page is to create a complementary site where women of size can post their pregnancy photos, belly photos, birth photos, breastfeeding photos, etc.  There are also discussion threads available.

Here is an excerpt their blurb:

The Ample Mother was started by two friends, both Ample Mommies! We wanted to create a safe, supportive community where other Ample Mommies could ask questions and share pictures and stories....
While we would like to promote exercise and good nutrition, we do so with the understanding that health is not synonymous with thin, and good health happens at all sizes! We will not focus on weight loss here.

We would like to encourage and enlighten women of size. Casting off the misconceptions based on bias and judgement in order to achieve the best pregnancy, birth and journey into motherhood that one can have....

ICAN Conference Next Week

Next week, the International Cesarean Awareness Network will hold their bi-annual conference.  It will be held in St. Louis, April 8-10. 

Leaders in the childbirth field such Dr. Geoge Macones, Henci Goer, Pam England, Dr. Poppy Daniels, Gail Tully, Geraldine Simkins, Dr. Emmanuel "Mike" Vlastos, and others will be speaking at the conference.  An agenda for the conference can be found here.

Here is a quote from an article about the conference:

"I think we've seen the bottom of the pendulum with the VBAC rate, and it will swing the other way," said Dr. George Macones, an expert in the safety of a vaginal birth after Caesarean.

Color me a little dubious since nothing has changed much in my area......but from his mouth to God's ears!  Since about a third of hospitals and about half of physicans currently do not offer VBACs, it's about time for the pendulum to swing back.

If you have not heard of ICAN before, here is some more information about the organization:

The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization that was founded by Esther Booth Zorn in 1982.

ICAN’s Mission Statement

To improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).

ICAN’s Vision Statement

A healthy reduction of the cesarean rate driven by women making evidence-based, risk appropriate childbirth decisions.

ICAN’s Statement of Beliefs

We, the International Cesarean Awareness Network, Inc., believe that:

1. The inappropriate over use of cesarean surgery is jeopardizing the lives of mothers and babies.
2. When a cesarean is necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved.
3. Birth is a normal physiological process. Research shows that with emotional support, education, and an honest opportunity, the vast majority of women can have a healthy vaginal birth.
4. A healthy birth incorporates emotional, physical, and spiritual well-being.
5. Research shows that VBAC is reasonable and safe for both mother and baby. A repeat cesarean should never be considered routine– it is major abdominal surgery with many risks.
6. It is unethical and unenforceable for hospitals to institute VBAC bans. Women have the right to refuse any procedure, including a cesarean.
7. Women have the right to true informed consent and refusal, which entails full knowledge of the risks and benefits of all tests, drugs, and procedures.
8. It is incumbent upon every care provider and institution to facilitate the informed consent process.
9. Women must be allowed to express all their birth related feelings in a safe and supportive environment. The emotions of a pregnant and birthing woman have profound effects on the birth outcome and recovery.
10. It is unethical for a physician to recommend and/or perform non-medically indicated cesareans (elective). Women are not being fully informed of the risks of this option in childbirth, and therefore make decisions based on cultural myth and fear surrounding childbirth.
11. The trend of “elective cesareans” is being significantly overstated through distortion of research and data.
12. We as women must now assume more responsibility for our own births.
13. It is critical that women’s choice of care provider and location of birth is respected.

Hope to see you at the conference!

Belly Blog Carnival Deadline Extended

I've gotten a number of submissions for my Belly Blog Carnival, which is great!  I'm thrilled. 

However, the original due date was tomorrow, and I've decided to extend it a couple more weeks.  I'm prepping right now for a big trip and presentation, and I'm realizing that I don't have the time to give the Belly Blog Carnival the attention it deserves before the trip.  I also want to give folks time to send further submissions.

So therefore I'm extending the deadline till after I get back from my trip, at which point I'll take time to collate all the submissions and write my own entry.

Let's make the new deadline April 15th.  Keep those submissions coming!

p.s. Don't you just love the picture above?  It's one of my all-time favorites.

Know Your Demographics, Stores!

While running errands this week, I decided to do a little clothes shopping and get some grown-up clothes for a trip I'll be making soon.  But I was so frustrated by the experience that I didn't buy as much as I would liked to have bought. 

So I need to air a pet peeve about plus-sized clothing stores.  I've been ticked off about this for many years now; I know a lot of others out there have had the same frustration.  Time to air it.

Now, I'm not one to blog about fatshion topics much; anyone who knows me knows I'm incredibly casual most of the time. I'm all about feeling comfortable and could care less if I look fashionable.  I like to look decent but it has to be comfortable above all else.  I'm about one step above slacker most days. I do have a some dress-up items and business clothes when more formality is needed, but most of the time I'm just looking for casual, comfortable, decent everyday clothes.  Shouldn't be that hard to find.....but it is.

I don't shop much because I don't have time to get out to the stores very often.  Also, I'm not an easy body type to fit; a lot of what's out there doesn't suit me.  So when I find something, I tend to buy it in 15 colors, just in case, and I tend to buy a lot of things at once so I don't have to come back often. I'm not a frequent or prolific shopper compared to some, but the stores can make some pretty decent money off of me if they have something nice-looking in my size.  And that's the problem, right there.  In my size.

So I'm at Catherine's this week, looking around. It's not my favorite store (seriously, do we need sequins on everything?  I like a little bling now and again, but this is overkill!), but it does have my size (26/28), which a lot of regular plus-sized stores don't have (they usually stop at 24).  Plus-sized choices in my size are fairly limited in my area without some serious driving, so when I do shop, it's often there.

What pissed me off was that the chain continues to ignore the demographics of its customers, overstocking the smaller sizes and seriously stinting on the larger sizes. 

They continue to order 50 zillion items in size 0x-1x (sizes 16-18 or so), and far fewer items in a size 3x or 4x (26/28 or 30/32).  Yes, they do have 3x, 4x, and even 5x items, but as a percentage of their offerings and in relation to their customer base, the bigger sizes are under-represented compared to the smaller stuff.

The customer base I consistently see in the store (me included) is usually 3x-4x.  I rarely see a 1x-sized woman in the store.  Sometimes, but not nearly as often as 3x-4x women.

So thus when you get to the sales racks, there is an abundance of 1x stuff that's NOT selling, and hardly any 3x-4x stuff, which is what most of the customers are looking for.  And even in its first-run items, the 3x and 4x sell out really quickly and it's hard to find items in those sizes unless you are there the week an item arrives.

I mean, really, retailers ─ get a #$%*ing clue!  People who wear a size 16 are usually able to shop in regular, "straight"-size stores.  Do you think most of them are going to Catherine's to shop?  I mean, I'm sure some do, but most do not.

Catherine's is a specialty store, and it's going to serve primarily the plus-sized woman who cannot shop at regular stores but doesn't want to take a chance ordering something blindly off the internet that may or may not fit.

These women are going to primarily be 2x-4x, with an especially high concentration of 4x (since 2x-3x is the size at which many plus-sized departments usually stop).  I mean, if I can buy a 2x shirt at K-Mart or Wal-Mart, why am I going to drive further and pay more to buy a similar shirt at Catherine's? 

The women who spend a lot of money at Catherine's are going to primarily be women on the larger side of the plus sizes. You would think that Catherine's would know and honor this, but apparently it doesn't.

To their credit, Catherine's does carry 5x, which is far more than many plus-size stores carry.  So kudos to them on that at least.

But come on, Catherine's, know your clientele!  Most of your customers are going to be women in the 3x-4x sizing, so you should be sending far more of those sizes to the stores, and fewer of the 0x and 1x items. Instead, it's the other way around, and the end result is too many small sizes extra afterwards and unsatisfied customers among the larger sizes.  Another example of size snobbery even among stores that cater to plus-sized women.

And it leaves me pissed off like crazy when I go there, see something really cute that I'd be interested in buying.....only to find out that they only have it in 0x and 1x anymore.  They really lose my goodwill when this happens.  Makes me not want to shop at their store very often, honestly. 

It's not just Catherine's, of course.  Lane Bryant has similar issues, as does Avenue and several others.  However, the demographics of those stores skew younger, so they are going to have a somewhat more substantial base in the 1x-3x size.  But it's not like younger women never wear size 4x!  They want cute clothes in their size, not granny stuff.  And even as middle-aged as I am, I'd shop those places more too if they'd just stock more 4x items (that are true to size).  They're neglecting part of their clientele too.

I have complained about this to store managers for years.  The managers always say, yes we KNOW, we've been telling corporate headquarters that for ages, but they don't listen.

COME ON RETAILERS.  KNOW YOUR DEMOGRAPHICS! 

Don't base your purchases on the demographics of how many fat women wear what size in the U.S., base it on the distribution of sizes of your clientele, the people who actually come and shop there.

You are cheating yourself out of a lot of sales when you skew too much to the smaller sizes. And you are pissing off the larger-sized clientele, often the ones with more money to spend. 

Stop the size snobbery, and stop alienating the very customers who are the heart of your business model. 

Are You Ready?

All the recent earthquakes in the world have made me want to post another reminder about the importance of having an emergency kit ready in your household, especially if you have children. 

Do you have at least enough supplies for 3 days?  That's the bare minimum you need for an emergency kit.  Do you have:

• Clean drinking water ─ 2 liters to 1 gallon per person per day ─ for 3 days? 
• Bleach or a good hiker's filter in case you need to sanitize more water for yourself? 
• Easily-fixed, non-perishable emergency food?  With a can-opener?
• A first-aid kit?  A first-aid instruction manual?
• A battery or wind-up radio and flashlight/lanterns?  Extra batteries? 
• Tarps and/or plastic sheeting, to help keep dry if you must take shelter outside? Duct tape and/or bungee cords to help secure it as needed?
• Blankets or sleeping bags or other ways to keep warm? 
• Rain ponchos, extra garbage bags, and plastic baggies to help stay dry?
• Moist towelettes, garbage bags and plastic ties for personal sanitation?
• A whistle to call for help if needed?
• Heavy-duty gloves, sturdy shoes, and other clothing to protect you from debris? 
• Matches in a waterproof container?
• A wrench or pliers to turn off utilities?

Other things that might be useful include dust masks, a map of your area, some cash or traveler's checks, a cell-phone charger, fire-starting tinder in a sealed plastic bag, some mess kit items (for eating/drinking), a fire extinguisher, folding shovel and/or small axe, Swiss army knife, paper and pencil, copies of your important financial information and ID, copy of contact information for out-of-state family, feminine hygiene supplies, and infant or pet supplies if needed.

A grab-and-go bag of the most portable of all these supplies (in a backpack, with a change of clothing) is always a good idea, should you have to evacuate your home quickly.  Also, you should have an emergency plan about where to meet if your family gets separated, how you'll get in touch with family outside of town, who gets the kids from school, etc.

Because many of us are special sizes that would be extremely difficult to obtain in an emergency if our own clothes were to get wet, dirty, or bloodied, I also think it's important that people of size keep an emergency bag with a full change of clothes readily available.

Keep a long-sleeved shirt, long pants, extra underclothes, and wool socks in there, plus an easily-rolled up coat or wool sweater etc. for warmth. Even the warmest areas of the country can get cold at night and staying warm is very important in an emergency. Pack wool or synthetic fabrics instead of cotton; if you get wet, wool or synthetics will keep you warmer even when wet.  Pack your clothing in a waterproof bag, so you are sure to have a clean and dry change if needed.

Why Make a Readiness Kit?

Some of you are saying, "Yeah, I've seen the news, but I don't live in an earthquake zone." Sure, not everywhere is located in an earthquake-prone area....but there's nowhere on earth that doesn't have at least some emergency hazard potential.  Your area may not be prone to earthquakes or tsunamis, but how about tornadoes, floods, blizzards, hurricanes, landslides, or wildfires?   There's always an emergency scenario possible, no matter where you are located.  It's best to be prepared no matter where you live.

And of course, there's the non-natural disasters, situations that could still result in long-term power outtages, food shortages, etc.  Or what about a major flu pandemic?  Or a sudden major downturn in the economy?  What if you could shelter in place but were without power and heat and a resupply of food for a long time?  What if the fresh water system in your area broke down?  How would you manage?

It always surprises me how many people don't have at least 3 days of food and fresh water they could live on if an emergency happened.  3 days, people.  That's not very long.  You really should have supplies for a lot longer than that.  And yet, so many people don't have even that.

So, if you don't already have an emergency kit, get one organized.  NOW.  Here's a website with some basic information on how to do so.

Take It In Baby Steps If Needed

There's lots we can do to prepare for an emergency. It can seem overwhelming to do all the things on the lists you see online, so begin with baby steps. Something is better than nothing, even if you don't have everything on the "should-have" lists. 

Start with whatever you can and slowly add to it as time and finances allow. Try dollar stores, drug stores, military surplus stores, thrift shops, and Ebay to help keep costs down. Use camping and hiking gear stores only for the most critical equipiment (for those, the best is worth the cost). Build your own kit in order to save money and to customize it for your family's unique needs.

Start with the 3-day supply of clean water, since water is one of the most critical of survival supplies, yet many people don't have this. Then move on a way to purify water, like bleach, a good filter or water purification tablets. Then move on to food, then first aid, then ways to keep dry and warm, then sanitary supplies. Then continue on from there, maybe devoting one evening a month or a season so you can spread out the time and the cost.

If you already have an emergency kit, good for you!  Take time to review it.  Has your food been rotated recently? Are the clothes in it the right size for the people in the house? Is the water fresh? 

If your kit is in good shape, can you add to your stash so you'd have more back-up supplies if needed? Make it for a longer period of time? Improve on what's in it? 

Ask yourself ─ is it stored where it's easily accessible in an emergency?  Do you have a smaller version already in your car or at work, in case you are not at home when an emergency hits?  Have you recertified in first-aid and CPR and emergency management courses recently?

It's okay not to have the "perfect" kit; just have something.  Think of building your kit as a process.  You'll learn more and improve things as you get more experienced.

Conclusion

Of course, no matter how much you prepare, sometimes it's not enough, you can't get access to your kit, or the disaster is so overwhelming that even the best emergency kit is not going to help.  An emergency is an emergency; sometimes a kit won't be enough, and some emergencies just aren't survivable.  We have to be realistic; a kit is not a magical talisman that guarantees our survival or protects us from disaster in the first place.

But in every disaster, there are always those who need emergency supplies like this afterwards.  If you are not one of the ones killed in the immediate aftermath of the event, chances are it's going to be a while before help is going to get to you, and chances are you may have to survive on your own for quite a while. 

Give yourself and your family the best possible chance for doing so.  Make sure you have an emergency kit stocked and ready, create a bug-out bag for yourself, have a disaster plan for reuniting/communicating, and have some emergency supplies in your car or at work as well. 

Hopefully you'll never need them ─ but if you do, having them may make all the difference in the world for you and your loved ones.  Recent events have given us a stark reminder of this.  Listen to the lesson and heed it.

Belly Blog Carnival!

The beauty of my body isn't measured by the size of the clothes it can fit into, but by the stories it tells. I have a belly and hips that say, 'we grew a child in here' and breasts that say, 'we nourished life.'

- Sarah from I Am Beautiful: A Story of Women in Their Own Words

In January and February, I wrote two posts called Belly Thoughts and Further Belly Thoughts.  They were about belly ambivalance, specifically about how my generally good body acceptance was challenged by pregnancy and birth, and how I sometimes still struggle with that.

However, even as I explored topics of body ambivalence, I tried to end on a positive note with an acknowledgement and honoring of the work our pregnant bellies had done.  I wrote about honoring my belly, I posted some pictures of how my older children painted my belly in the last weeks of my last pregnancy, and I discussed how much those pictures meant to me.

That was my way of trying to bring the conversation back to a positive place, because even as I am challenged to fully love the changes in my body brought about by age and multiple pregnancies, I also do not regret having had children, not for a single moment.  My children are more than just compensation for the changes that have happened to my body.

As I've written before, I think it's a crime that there are not more images of women of size pregnant, birthing, breastfeeding, and parenting.  I certainly could have used some images like that when I was first pregnant and afterwards, and I know many other women of size feel the same.

Most of the information out there on fatness and pregnancy is very negative, and rarely do you see any pictures at all in the media ─ let alone beautiful pictures ─ of women of size in pregnancy and afterwards.  And we need images like those. 

And many of us, trained to be self-conscious or ashamed about our size, neglect to document our own pregnancies in any significant detail, whether that be with belly pictures, birth pictures, breastfeeding pictures, or parenting pictures.  Far too often we take the pictures, instead of letting ourselves be the subject of pictures, and that just adds to the lack of documentation out there....and the lack of documentation of our own lives.

And we need documentation.  We need to STOP being invisible mothers.  We need ─ and deserve ─ to be seen.  We deserve to take up space in the world as women and as mothers.

A number of you have sent me pictures of yourselves pregnant as a result of my post about the lack of images, and I think this is awesome.  Thank you to everyone who has sent in or shared their pictures with me.  I have so enjoyed them.

However, I've been a little reticent to use some of them on the blog because of the fear that a troll might take these pictures and abuse them.  Unless you have made it really clear to me that you are okay with your pictures being online forever like this, I usually haven't used them, just to be cautious.

But even as I worry about these things, I've decided it's really important that we declare our independence and post our pictures anyhow.  It's SO important that there be pregnancy and parenting images of women of size out there, showing that we do have babies, we do give birth, we do breastfeed, and we do parent.

We women of size are women, just like other women, and we have families, just like other women.  It's about time we got more documentation of that.  And it's about time we celebrated that more, instead of hiding whenever the cameras come out.  It's time we became visible moms.

So as a positive coda to my series on belly thoughts, I would like to propose a BELLY BLOG CARNIVAL. 

If you have had children, blog about your pregnancy belly and body, and post pictures too.  Document your experience in words and/or in pictures, and share your feelings ─ positive,  negative, challenges and all. 

If needed, please use trigger warnings out of respect for others, but I would ask that everyone try to end with a focus on the positive, if at all possible.  We can document our challenges, but let's also not forget to celebrate our bodies.  I especially welcome entries which celebrate their bodies in creative ways.

When you have posted your entry, send me a link to it (with a brief summary of what it's about). You can send it to kmom  [AT]  plus-size-pregnancy [DOT]  org.  Send it by March 31st, 2011.  Then I'll summarize everyone's posts together (with links) in one place here on my blog sometime in April.

If you don't have a blog and just want to share a picture, you can email that to me as well, along with permission to use the picture and whatever brief information  you want to appear with it. I generally discourage the use of real names, since this will be available online forever, but if you are absolutely positive you want this picture of you, identified with your name, available forever (the logistics are too much if you change your mind and want to delete it later), I will publish that as needed. Depending on how many I receive, I may put it in one big post, spread them out over a number of posts, or open a Tumblr account or something (if I can figure out how...I'm new to that!). 

(If you send me a picture, please remember to give me explicit permission to use your picture or I won't post it.  People often send me a picture but forget to add permission, and I don't have time to do follow-ups to get that.  In addition, if you'd like to include permission for me, kmom, to use your picture in whatever way I need for future posts, articles, presentations, publications, etc., I'd love to have that as well.  I'm always interested in adding to my gallery of plus-sized pregnancy and parenting photos to use as needed in my various projects. I welcome pictures from everyone but am particularly in need of pictures of any stage of pregnancy or parenting from women of color, and pictures from women of size during labor and birth.)

In summary, it's time to cap this belly discussion with a positive finale.  Over the next few months, expect to see periodic pregnant belly pictures on my blog from various women of size. We may even have related posts about belly casts, belly henna, belly painting, and other things we as women of size can do to celebrate our beautiful lush pregnant bodies. 

Bring on the bellies!!

*And isn't that picture from "Lyista" at the top of this post just the MOST gorgeous belly photo ever?  My thanks to her for sharing and for giving me permission to use the photo!