About Time: Good News for Vaginal Birth After Multiple Cesarean!

FANTASTIC NEWS!!!

The American College of Obstetricians and Gynecologists (ACOG) has finally issued a revision of their 2004 guidelines on Vaginal Birth After Cesarean (VBAC).  [About time.]

In the new guidelines, ACOG changes positions on a few key elements.  The position changes of greatest import are the ones providing more flexibility for choosing VBAC even when staff aren't "immediately available" on-site to provide emergency care if needed, and the recognition of patient autonomy (the right of each patient to choose VBAC or repeat c-section for themselves, not have it imposed on them by doctor or hospital bans). 

I leave discussion of those topics to other bloggers and ICAN for now (I may eventually comment too...believe me, I have plenty to say on the subject!). Right now the part I most want to comment on is a REVISION of their policy on Trial Of Labor After Cesarean (TOL or TOLAC) in women with 2 prior cesareans.  Hallelujah! 

New Guidelines for VBA2C

Here's the summary about VBAC after 2 prior cesareans (VBA2C)  from the new ACOG guidelines:

Women with two previous low transverse cesarean deliveries may be considered candidates for TOLAC.

Previously, in the 2004 guidelines, women with 2 prior cesareans were only considered candidates for a trial of labor if they'd already had a vaginal birth.  Without that, women with more than 1 prior cesarean were supposed to be automatically sectioned for any subsequent children.

But now women with 2 prior cesareans can go for a VBAC, regardless of whether they've had a prior vaginal birth. Yes!!!

This is a cause for major celebration for women like me who have had more than one prior cesarean. Granted,  it doesn't make any difference for me personally, because I had my first VBA2C before the 2004 guidelines went into place. I had my second VBA2C after the guidelines, but because I'd already had a vaginal birth at that point they didn't apply to me.  And since I'm done having children, it's moot for me now as well.

But that's all coincidental timing.....I could easily have been affected, and I never forget that.  Most of the hospitals in my city, while still mostly supportive of VBAC, have stopped attending VBAMC completely.....even the University Hospital that has 24/7 anesthesia and OBs on-site.  If I were having my babies now, I'd be out of luck.

But while this doesn't affect me anymore, I care because of all the women I know who have had to search desperately (and often unsuccessfully) well into their pregnancy to find a care provider who would "let them try" a VBAMC, and who have had to endure scaremongering and egregiously inflated risk estimates from various "caregivers" along the way.

I care because of the good, honorable care providers who have been threatened with losing their privileges because they do support VBAMC, or who have been pressured or harassed out of attending VBAMC.

I care because an ICAN friend of mine had a VBA2C this week only because homebirth midwives in her area continue to support VBAMC (the hospitals in her area do not). Otherwise this friend of mine would now be recovering from yet another operation, all while trying to take care of a newborn and 2 toddlers.

I care because of all the women I know who have had to choose between being forced into repeat surgery they didn't need and an out-of-hospital birth that they may not have been comfortable considering. While homebirth is a reasonable choice and most of the VBAMC moms I've known in recent years have chosen a homebirth because it offers their best chance of success, not all women are comfortable with this option and it shouldn't be their only choice for avoiding surgery.

I care because of the women who have been threatened with Child Protective Services if they dared consider a VBA2C.  (The woman in this article isn't the only one.)

I care because of the women who were told they were almost sure to kill their baby if they dared to try a VBA2C. Like this woman, who was told:

“Unless you have an elective cesarean at 38 weeks, the baby and you will die.”  -OB to mother with two prior cesareans  (from My OB Said WHAT?!?)

I care because of all the women with 2 or more prior cesareans who have been coerced or scared into repeat cesareans, despite the many complications multiple repeat cesareans exposes them to (Silver 2006). 

I care because of the women I know who came into the hospital well into labor (sometimes even pushing) but who were strapped down and sectioned anyway, despite their protests, simply because of a history of 2 prior cesareans.  One (a doctor herself) sustained significant internal damage from the surgery, and another was denied pain meds for a while after the cesarean "to teach her a lesson."  Another went on to nearly die from placenta accreta in her next pregnancy.

I care because of the women I know who have been coerced into repeat cesareans and have encountered severe complications in subsequent pregnancies (placental attachment issues, uterine rupture, hysterectomy, and stillbirth). 

The 2004 ACOG guidelines had consequences, sometimes dire ones; we must never forget that, and we must never let ACOG forget that either.

It's great to finally have some acknowledgement (belated though it may be) that VBA2C is a reasonable choice, that it does not carry a big excess of risk, and that women have the RIGHT TO CHOOSE their mode of birth.

But I'm pissed that the ripples from the 2004 guidelines are going to continue to echo for many years to come and I'm ticked as all get out that it took so long and so much harm to women and babies before ACOG changed its policy back again.

Bad Science, Birth Politics, and VBAMC

After supporting VBAC after Multiple sections (VBAMC) for years, ACOG backed away from it in their 2004 guidelines. The change was highly political,  as I've written about before. It wasn't based in good science, but rather on birth politics and one small, poorly-done study.

In 1999, Caughey et al. published a study of 134 women with a TOL after 2 prior c-sections, and it found a Uterine Rupture (UR) rate of 3.7%.

It didn't matter that no study on VBAMC before or since has found such high numbers, and it didn't matter that the study only involved 134 women and therefore the small sample size could easily distort the findings, creating the illusion of more severe risk than really was there........in the VBAC-lash climate, this became THE study to go by.

It didn't matter that the study had only 134 TOLs in 12 years, that extremely aggressive prostaglandin and pitocin policies were used at this hospital during those years, and that there were NO ruptures in the spontaneous labor VBA2C group.  No, ACOG decided to ban ALL VBA2C unless there was a prior vaginal birth, based on the data from this one small study.

The backstory here is that many care providers were already backing away from supporting VBACs of any kind.  If they could find any excuse to justify ending yet more trials of labor, they'd take it........and they did.

It's not a coincidence that one of the lead authors of this 1999 study was one of the main authors of the 2004 ACOG revised guidelines. She and the others basically ignored or dismissed all the other studies that found far lower rupture rates and focused only on that one in making the decision to recommend against VBAMC without a prior vaginal birth.

Birth politics, anyone?  With women and babies paying the price.

More Recent and Much Larger VBAMC Studies

Since the 2004 guidelines, two other FAR larger studies have found rupture rates much much lower than the Caughey 1999 study in VBA2C women.

Macones 2005 had a study group of 1,082 women, a far larger study group than the Caughey study.  It found a rupture rate of 1.8%, with 16 of the 19 ruptures found in the induced or augmented groups.  This suggests that the rupture rate could have been even lower. 

The authors didn't state the spontaneous rupture rate in the study but I crunched the numbers myself based on the percentages of induced, augmented, and spontaneous labors given in their data tables.  The spontaneous rupture rate in the VBA2C group was 3 out of about 379 spontaneous labors, or about 0.8%, compared to 16 ruptures out of about 703 induced or augmented labors, or about 2.3%.

Although it's impossible in hindsight to know exactly how many ruptures might have been prevented by avoiding induction and augmentation, it's a good bet that the total rupture rate would have been lower than 1.8%.  Thus, this number may not represent the true rupture risk for spontaneous labor VBA2C.

Landon 2005 had a study group of 975 women, also far larger than the Caughey study, and included a small group of women (n=104) with 3 or 4 prior cesareans in its data pool.  It found a VBAMC rupture rate of 0.9%, and that was with inductions and augmentations.  Therefore, the spontaneous labor rupture rate is probably even lower in that study. [I've asked Dr. Landon for the (unpublished) spontaneous labor rupture rate but unfortunately, so far he has not responded.]

A slightly smaller study, Lin and Raynor 2004, confirms that the rate of rupture is smaller in the spontaneous labor VBAMC group.  The full text of the study notes that there were 523 spontaneous labors in the VBAMC group, and this spontaneous labor group had a 0.8% rupture rate.  There were 2 ruptures in the 73 induced labors for a 2.7% rupture rate.

This is information that is very important.  Really, it's the spontaneous rupture rate that is the MOST important to consider when making a decision about whether to consider VBAMC. Women and their caregivers need to know that the VBAMC rupture rates usually quoted are rates distorted by induction and augmentation and that the true risk is likely much lower with spontaneous labor, as it is with VBA1C.

This is the information not being disclosed in the new ACOG guidelines.  They dance around the induction and augmentation issue, noting that a number of studies have found an increased risk of rupture when a trial of labor was induced, but diluting that by mentioning that some studies have only found increased rupture risk in women without a prior vaginal birth or when prostaglandins are used in conjunction with pitocin. 

However, the bottom line is that the lowest rates for uterine rupture are found in the groups of women with spontaneous labor....no induction, no augmentation....and that this is true also for VBAMC women.

Quoting a VBA2C rupture risk as 0.9 - 1.8% makes it sound like this is the risk even if the labor is spontaneous, and it likely is not.  VBAMC research needs to start differentiating between results for totally spontaneous labors, labors augmented with pitocin, and different types of induced labors, as VBA1C research often does. 

Yes, we need more studies with VBAMC spontaneous labors to confirm these numbers, but many more doctors and women might be willing to consider VBA2C if they understood that the real risk of rupture is more like 0.8% or so if labor is spontaneous. 

Full Text of ACOG's New Guideline on VBAMC

Here is the full text of ACOG's new guideline on VBAC after more than one prior cesarean.  I've substituted their study reference numbers with the author/year for clarity here, and also broken up the information into paragraphs for readibility.  The full citations for these studies are at the end of my blog post, with links to their abstracts. While I don't agree with all of ACOG's conclusions, I include the full section here for the sake of documentation:

More Than One Previous Cesarean Delivery

Studies addressing the risks and benefits of TOLAC in women with more than one cesarean delivery have reported a risk of uterine rupture between 0.9% and 3.7%, but have not reached consistent conclusions regarding how this risk compares with women with only one prior uterine incision (Asakura 1995, Caughey 1999, Landon 2006, Macones 2005, Tahseen 2010).

Two large studies, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC (Landon 2006, Macones 2005). One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries (Landon 2006), whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries (Macones 2005). Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2% composite major morbidity in one study) (Macones 2005).

Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.

Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited (Cahill 2010).

What About VBAC After 3 or More Prior Cesareans?

Women who have had more than 2 prior cesareans are no doubt wondering how this all applies to them and whether they will be left out in the cold.  Basically, the new guidelines leave the question open-ended.

In the past, while ACOG guidelines did not exactly advocate for VBAC after 3 or more cesareans, it did not ban them either. The 1994 guidelines stated:

A woman who has had two or more previous cesarean deliveries with lower uterine segment incisions and who wishes to attempt vaginal birth should not be discouraged from doing so in the absence of contraindications.

In other words, it was left up to the judgment of the managing care providers and the birthing mother.

The new 2010 ACOG guidelines state that women with 2 prior cesareans are candidates for a TOLAC but that the data on women with 3 or more prior cesareans are limited.

Unfortunately, it is true that we don't have a lot of data on VBAC in women with 3 or more prior cesareans.  Higher-order VBACs have happened, but rarely in any kind of large, systematic way. Several studies have had small numbers of VBAMC TOLACs, but the sample sizes were not large enough for any real conclusions.

There is only one somewhat substantial study of higher-order VBACs. Miller (1994) had 1,827 TOLs in women with 2 or more cesareans. Of these, there were 241 TOLs in women with 3 or more prior cesareans.

Overall, the rupture rate was found to be 1.7% in all VBAMCs combined; 1.8% in VBA2Cs, but only 1.2% in VBA3+Cs. This seems to contradict the theory that rupture risk rises linearly as the number of prior incisions rises. However, these labors may just have been managed with more caution (i.e., less induction and augmentation), thus decreasing the risk of rupture. Without more details, we cannot know. But the 1.2% rupture risk in the higher-order VBAC group is within the 0.9-1.8% risk cited for VBA2C in the new guidelines, so it seems logical that higher-order VBACs should not be categorically denied either.

Despite the discouragement of VBAMC, some women are still managing to have higher-order VBACs, although it is harder now than in the past. The highest-order VBAC documented in the medical literature is a VBAC after 5 cesareans (Veridiano 1989). Wood (2001) documented a VBA4C in Australia. There are anecdotal stories on my main website of  VBA3C, VBA4C, even VBA7C births.

A few recent studies are starting to broach the question of higher-order VBACs again.The Landon 2006 study documented 104 TOLs in women with 3 or 4 cesareans, 84 with 3 prior cesareans and 20 with 4 prior cesareans. Cahill (2010) documented 89 TOLs in women with 3 prior cesareans, all with "no cases of composite maternal morbidity" (i.e. no ruptures, bladder or bowel injury, or uterine artery laceration), and a slightly higher success rate than VBA1C cases (79% vs. 75%).

More data (from large, well-designed studies) are urgently needed to properly evaluate the risks in higher-order VBACs, but the data we have so far suggest that a trial of labor should not be ruled out. Furthermore, any consideration of possible uterine rupture risks in higher-order VBACs must also be balanced against the substantial risks of continuing cesareans (Silver 2006), particularly in women who want larger families.

The good news is that the new guidelines, while not endorsing higher-order VBACs, do not rule them out either.  They merely state that more data are needed.  The fact that the guidelines do not outright preclude them leaves the back door open to doctors and midwives willing to attend higher-order VBACs.  This, plus the mini-trend towards more research on VBAMC, suggests that maybe even the front door could open eventually to the possibility of higher-order VBACs.

Concluding Thoughts

Even though I'm thrilled beyond words that ACOG has finally revised its guidelines, my joy is tempered by outrage that those bad-science 2004 guidelines will continue to have ripple effects for many years to come. 

The Macones study (2005) called for a re-evaluation of the ACOG guidelines on VBAMC. The authors wrote:

It seems reasonable to consider VBAC in those with 2 prior cesareans with no prior vaginal delivery, especially if they go into labor spontaneously.

Landon et al. (2006) also called for VBAMC to remain an option:

A requirement that a history of vaginal delivery be present in women with multiple prior cesarean deliveries to be considered candidates for trial of labor seems unwarranted given the apparent level of risk for uterine rupture and adverse outcomes in this population.  Moreover, a comparison of outcomes after trial of labor in women with multiple prior cesarean versus those undergoing elective repeat operation indicates that both options should remain available for eligible women.

Yet it still took four to five more years for ACOG to actually change those guidelines! And during that time, how many more women got forced into repeat cesareans they didn't want or need? 

The SOGC, the Canadian equivalent of ACOG, stayed open to VBA2C on paper, as did some other countries....but the fact is that the climate for VBAMC chilled considerably around the world because ACOG changed its guidelines. 

How many women have been butchered in the last six years because of ACOG's unscientific response to a study with only 134 participants? 

How many will continue to be butchered even after the rule change because doctors now have a distorted sense of risk around VBAMC, or because some malpractice insurance companies refuse to cover doctors or hospitals that "allow" VBAMC? 

Many OBs are never going to go back to "allowing" VBAMC on a regular basis. Like breeches, that horse is out of the barn door and it's not coming back, at least not any time real soon.

Thanks to the Caughey 1999 study and the ACOG 2004 guidelines, many docs will stay with a policy of "twice a cesarean, always a cesarean." They know that scheduled cesareans are more convenient schedule-wise and less risky liability-wise anyhow. They're not going to go back anytime soon, even with the new rules.

So while I'm thrilled that ACOG has finally changed their VBA2C rules, I'm still absolutely LIVID that the 2004 rule change (based on bad science and bad birth politics) resulted in so many women being exposed to so much unnecessary risk.  And I'm even MORE livid that this stupid rule change is likely to go on affecting women's choices around the world for a long time to come, despite it having been rescinded. 

However, I'm trying to remember the positive. 

[Deep calming breath.]

This IS a big step in the right direction, after all. It took a big kick in the behind from the NIH VBAC conference this past year to get it going, but at least there is some momentum in the right direction now. Yessss!!!!!

It at least opens the possibility for VBAMC again for those providers who wanted to support it but felt they couldn't go against the ACOG guidelines and the standard of care in their community. Doctors and midwives need to be able to support VBAMC without feeling they are at extra risk legally for doing so.

This new guideline gives women who want a VBAMC a leg to stand on.  If their doctor tells them they cannot have a TOL, they can show the doctor the ACOG guidelines and point out that they have the right to refuse a repeat cesarean and cannot be coerced into one. 

I'm not holding my breath, waiting for a tidal wave of VBAMCs. Doctors largely ignore contradictory evidence when it goes against the way they want to practice. It's all about convenience and perception of risk these days, and I'm not sure how far ACOG rule changes will go towards altering the prevailing obstetric culture of birth.

Rest assured, though, that there ARE docs and midwives who are "allowing" a TOL after 2 or more cesareans anyhow (thank you, Dr. Landon and Dr. Tate!). They are few and far between.....but there are still some out there. And BLESS THEM for standing against the ACOG machine and standing up for what's right!

And good for ACOG and its current leadership for recognizing and trying to resolve some of the harms that were caused from the 2004 guidelines. This ACOG leadership is a refreshing breath of air compared to some past regimes, and by and large, the Committee on Practice Bulletins (aided by Dr. William Grobman and Dr. Jeffrey Ecker) did a good job of balancing difficult policy questions in this new bulletin.

Now I'm waiting to see MORE providers out there, willing to stand up for women's autonomy in decision-making. Take a stand, providers; nearly half of all U.S. hospitals ban VBACs of any kind and the rate is much higher for VBAMC.  It's time to make your voice HEARD.  It will take lots of pressure on the part of both consumers and healthcare providers for the change to happen. Stop letting the majority of the momentum come from consumers and start adding your voices back to the discussion!

Oh, and ACOG, if you truly believe in women's autonomy in making their own decisions (as you insist you do), it's time to start pressuring more hospitals to reduce their preventable primary cesarean rates.  Don't just pay lip-service to the idea of autonomy; true patient autonomy includes more of a voice in all decisions, not just VBAC decisions. That includes making sure women have the choice of vaginal birth in the scenarios that lead to a lot of "elective" primary cesareans (breech babies, big babies, "late" babies, etc.).  If we reduce the primary cesarean rate, then we can reduce the need for VBACs markedly.

ACOG, this was a decent first step; now back it up with further action.

No woman should be forced into surgery if she doesn't want it.  She should consider the pros and cons of all her choices, but she should choose from a place of knowledge, not a place of coercion.  She should receive counseling from her healthcare providers about the risks and benefits of her various options, but ultimately, the choice should be hers. 

At least we finally have some ACOG recommendations to support that, and which recognizes that VBAMC is a reasonable choice after all. 

About time.


References

Veridiano NP. Vaginal delivery after cesarean section. International Journal of Gynaecology and Obstetrics August 1989;29(4):307-11. PMID: 2571531

ACOG Committee Opinion. Vaginal delivery after a previous cesarean birth. #143, October 1994.

Miller DA et al. Vaginal birth after cesarean: a 10-year experience. Obstetrics and Gynecology August 1994;84(2):255-8. PMID: 8041542

Asakura H, Myers SA. More than one previous cesarean delivery: a 5-year experience with 435 patients. Obstet Gynecol 1995;85:924–9.  PMID: 7770261

Caughey AB et al. Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries. American Journal of Obstetrics and Gynecology October 1999;181(4):872-6.  PMID: 10521745

Wood JR, Quinlivan JA, Keirse MJ.  Trial of labour after four Caesarean sections: a case report and literature review.  Aust N Z J Obstet Gynaecol 2001 May;41(2):233-5.  PMID: 11453282

Spaans WA et al. Trial of labour after two or three previous caesarean sections. Eur J Obstet Gynecol Reprod Biol Sept 10, 2003;110(1):16-9.  PMID: 12932864

ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Vaginal birth after previous cesarean delivery. #54, July 2004.

Lin C and Raynor D. Risk of uterine rupture in labor induction of patients with prior cesarean section: an inner city hospital experience. American Journal of Obstetrics and Gynecology 2004;190:1476-8.  PMID: 15167874

Macones GA et al. Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option? American Journal of Obstetrics and Gynecology 2005;192:1223-9.  PMID: 15846208

Landon, MB et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.Obstetrics and Gynecology July 2006;108(1):12-20.  PMID: 16816050

Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Obstet Gynecol 2006;107:1226–32.  PMID: 16738145

Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2)-a systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG 2010;117:5–19.  PMID: 19781046

Cahill AG, Tuuli M, Odibo AO, Stamilio DM, Macones GA. Vaginal birth after caesarean for women with three or more prior caesareans: assessing safety and success. BJOG 2010;117:422–7.  PMID: 20374579

ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Vaginal birth after previous cesarean delivery. #115, August 2010.

Being Human

A quick post to promote the BBC series, Being Human. It's a series about a vampire, a werewolf, and a ghost who all share a flat in Bristol, England and try to discover what it means to "be human." 

The show is funny, scary, and at times, quite compelling in its storylines.  The actors are good, especially Russell Tovey as George the Werewolf.  He twitches and overacts and chews the scenery (sometimes literally) but somehow pulls it off anyhow with cheek and a touching vulnerability.  Annie the Ghost starts off as weak-willed and victimized but gains strength and chutzpah by the end of the series and it's a nice transformation to behold.  Mitchell the Vampire is a bit more muddled but even so, the character works, especially in his interactions with Annie and George. 

This was first produced as a one-off show, a pilot without a commitment to a series, a few years ago.  It gained enough of a following that it returned as a 6-episode series follow-up, albeit with new stars in 2 of the 3 main roles.  Season Two begins soon on BBC America.  Season Three has been ordered (but reportedly will move to Cardiff, Wales), and the SyFy Network in America has ordered an American remake of the series (bleah, they should have just gotten the BBC series rights).

The British version was written by Toby Whitehouse, who has written episodes of Doctor Who and Torchwood.  Now, while my husband and kids love Dr. Who, I'm not quite as big a fan......but I loved this show.  It was a huge surprise, and a very pleasant one.

Being Human really is worth giving a chance to, even if you're not a big sci-fi buff.  The vampire blood bits and the final werewolf effects are way cheesy (as all screen vampire and werewolf stuff inevitably is) but a lot of other stuff is more unexpected and less cheesy.  There is some horror stuff, be warned, but it's not horribly excessive. The best part of the show is the humor; we laughed quite a bit at the show and we totally didn't expect to.  There were also some touching moments to balance the humor and the horror bits.

Right now, you can catch Season One in repeats on BBC America or other channels as a lead-up to the premiere of Season Two on BBC America this weekend.  If you can, I highly recommend watching the whole of Season One first.  The story arc starts off a bit weak but gets stronger, and the Season ends with a bang.  Definitely worth seeing before trying out Season Two. 

I have no idea if Season Two will be any good.....sometimes you get a really promising Season One and a huge disappointment in the next season.  But if you are a sci-fi fan at all.....and maybe even if you're not.....this series is definitely worth checking out. It has been one of our favorite new shows of the year.....and it's great to have new content to watch in the summertime.  Give it a chance!

Limiting Fertility Treatment Access for Fat Women

Finally, a breath of fresh air reply from the research journals to the many folks advocating that fat women not be allowed access to fertility treatment (as they are not in Britain).

Should access to fertility treatment be determined by female body mass index?


Hum Reprod. 2010 Apr;25(4):815-20. Epub 2010 Feb 3.
Pandey S, Maheshwari A, Bhattacharya S.
Assisted Reproduction Unit, University of Aberdeen, Aberdeen Maternity Hospital, Forresterhill Road, Aberdeen AB25 2ZL, UK.

Abstract

Resource allocation towards fertility treatment has been extensively debated in countries where fertility treatment is publicly-funded. Medical, social and ethical aspects have been evaluated prior to allocation of resources. Analysis of cost-effectiveness, risks and benefits and poor success rates have led to calls of restricting fertility treatment to obese women. In this debate article, we critically appraise the evidence underlying this issue and highlight the problems with such a policy.

Poor success rate of treatment is unsubstantiated as there is insufficient evidence to link high body mass index (BMI) to reduction in live birth. Obstetric complications have a linear relationship with BMI but are significantly influenced by maternal age. The same is true for miscarriage rates which are influenced by the confounding factors of polycystic ovary syndrome and age. Studies have shown that the direct costs per live birth are no greater for overweight and obese women.

With changing demographics over half the reproductive-age population is overweight or obese. Restricting fertility treatment on the grounds of BMI would cause stigmatization and lead to inequity, feelings of injustice and social tension as affluent women manage to bypass these draconian restrictions. Time lost and poor success of conventional weight loss strategies would jeopardize the chances of conception for many women.

PMID: 20129994

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

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

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

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

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

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

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

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

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

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

One Woman's Story

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

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

My Reply:

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

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

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

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

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

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

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

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

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

*Anybody out there ever hear this chestnut?

Words of Sense in the Boston Globe: Now Apply Them to Women of Size

Check out this great new op-ed opinion in The Boston Globe from Judy Norsigian (of Our Bodies, Ourselves) and Dr. Timothy R. B. Johnson (Bates professor and chair of the Department of Obstetrics and Gynecology at the University of Michigan).

In the op-ed, the authors discuss the high costs of cesareans, both financial and medical, and the non-medical factors that lead to more cesareans. 

Even though caesareans are associated with higher rates of complications than vaginal births, they are becomingly increasingly common. Problems range from infections, including the more serious antibiotic-resistant ones, to blood clots, prematurity, respiratory problems for the baby, and more complications with subsequent pregnancies. There is even a small but measurably higher risk of death for the mother...

There are also cost consequences for taxpayers — the caesarean rate for Massachusetts mothers on Medicaid is increasing at a faster pace than among privately insured mothers. Nationally, in 2008, average hospital charges for an uncomplicated caesarean section were $14,894, while such charges for an uncomplicated vaginal birth were $8,919.

In the media, most of the blame for the increasing cesarean rate has been placed on the mothers, rather than on doctor practices and medico-legal concerns.  Mothers are blamed for being too old, too fat, too high-risk......supposedly that's why the cesarean rate is rising.  But the article quickly skewers this reasoning:

Between 2000 and 2006, while the Massachusetts caesarean rate climbed from 16th to 10th highest among all states, the state’s ranking on neonatal mortality has slipped from 4th best to a tie for 9th. Six hospitals in the state have caesarean rates greater than 40 percent for first time mothers, yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.

Now, I would like to have seen more from the authors addressing (and questioning) the issue of obesity "causing" high cesarean rates, but I love how succinctly they suggest commonsense options for improvements in the overall cesarean rate (emphasis mine).

What can we do to lower the caesarean rate? Considerable media attention has focused on how extreme obesity can raise the risk of having a caesarean, but more emphasis is needed on these system-based approaches:

• More hospitals need to institute policies that restrict the induction of labor, unless there is a good medical reason...
• Obstetricians and hospitals should follow the new National Institute of Health recommendations to offer the option of vaginal birth after a caesarean for those women who want to avoid repeat surgery...
• Hospitals could expand access to nurse-midwifery care. In Boston, statistics for hospitals that care for women facing the same risk of complications show that hospitals with nurse-midwifery services tend to have lower caesarean rates than those without a significant midwifery presence.

These suggestions are so common-sense that they have a big "DUH" factor.....yet they are not routinely used in many hospitals. 

The induction rate today is completely out of control....and it's not all "inductions of convenience" just because the mother is tired of being pregnant, as some doctors claim.  For the most part, doctors are behind the epidemic of inductions these days, for reasons of fear, of convenience, and because they are in denial about the very real risks of induction.  WE MUST STOP INDUCING LABOR SO OFTEN.

Denying women the right to VBAC is a violation of human rights, pure and simple.  No one should be forced into surgery they don't want or need.  Everyone, including pregnant women, has the the right to bodily autonomy and the right to informed consent/refusal.  Even ACOG's own position paper says that women have the right to make their own decisions on their medical care.  This should include the right to choose a VBAC and/or refuse a planned repeat cesarean:

Once a patient has been informed of the material risks and benefits involved with a treatment, test or procedure, that patient has the right to exercise full autonomy in deciding whether to undergo the treatment, test or procedure or whether to make a choice among a variety of treatments, tests, or procedures.  In the exercise of that autonomy, the informed patient also has the right to refuse to undergo any of these treatments, tests, or procedures...Performing an operative procedure on a patient without the patient's permission can constitute "battery" under common law.  In most circumstances this is a criminal act...Such a refusal [of consent] may be based on religious beliefs, personal preference, or comfort.  --ACOG Committee Opinion #237, June 2000

Finally, access to midwifery care should be the right of every woman, but more and more hospitals, doctors, and insurance companies are closing down midwifery-friendly hospitals, phasing out nurse-midwifery practices, and trying to restrict/outlaw out-of-hospital midwifery.  Midwifery is a more economical choice and has equivalent or better outcomes for most women and babies....yet it is not available to many women, and some authorities are trying to actively cut off access for still more women.  This makes NO financial or ethical sense!

In particular, I would like to see the above systematic suggestions applied to women of size.  Women of size are routinely induced at extremely high rates, and are increasingly being denied access to VBACs and to midwifery care.  Let's see if restricting inductions, allowing (and encouraging!) VBACs, and expanding access to low-intervention midwifery care might lower the rate of cesareans in "obese" (and "extremely obese") women as well. 

If these suggestions work as systematic solutions for lowering the cesarean rate in all women, they should help lower the cesaran rate in women of size too.  Funny how folks have blinders on in applying these suggestions to "obese" women, though, eh?

Defective Cervixes in "Overweight" Women

From the blog, My OB Said What???

"Women With A BMI Higher Than 26 Tend To Have Cervixes That Won’t Dilate…."

"Well, in my experience, women with a BMI higher than 26 tend to have cervixes that won’t dilate without chemical induction.”

– CNM to overweight woman

Oh puleeeeze.  I know doctors and even some midwives say a lot of stupid things to women, but OMG, what an idiotic thing to say.

Well, apparently my cervix didn't get the memo, despite me having a BMI in the 40s.  It dilated just fine in all four pregnancies, induced or not induced.  I know an awful lot of other fat women whose cervixes didn't get the memo either.

Alas, we can roll our eyes at it all we want, but there are an awful lot of medical professionals that actually believe this crap. It's not the first time I've heard it or something like it, but it's especially appalling to hear it from a midwife, for heaven's sake.

Yet another reason for the epidemic of inductions in women of size........and since inductions raise the risk for cesareans strongly, for the epidemic of cesareans in women of size.

But rest assured, fat women's cervixes dilate just fine too.....and especially when our pregnancies are dated correctly (adjusted for cycle length), and when our own bodies' timelines are respected.  [Oh wait, that's a whole 'nuther pet peeve post!]

Happy Birthday to Me!

Happy birthday to me!!  Or at least, happy birthday to my blog. 

2 years ago this month I started this blog to try and reach out to more people in the fat acceptance community and in the birth community.  Although a number already knew about my http://www.plus-size-pregnancy.org/ website, many did not, so it was a good way to raise awareness about pregnancy in women of size, birth politics in general, and size acceptance issues in general as well. 

To celebrate my blog's birthday, I have redesigned its template a bit.  Tell me what you think.  And thank you all for coming and reading my thoughts and for sharing yours!

Ultrasounds in Women of Size, part 1

Recently, a commenter asked about ultrasounds in women of size, and I'd like to briefly address that here and then refer folks to the very in-depth article I have on the topic over at my regular website. 

Remember, if you don't see your question answered here on this blog, I do have my http://www.plus-size-pregnancy.org/ website that covers a lot of these topics in far more detail, complete with research references. The two sites are meant to be complementary.  If you don't see an answer here, be sure to check out my main website.

[Normally, I'd answer the commenter's question on the page of the original post, but I can't easily figure out which post that is.  If there is some way on Blogger to know which post a comment goes to once approved, please let me know!  Otherwise I end up having to go back through zillions of posts trying to figure it out.  I make a best-guess stab at it and if I can't find it easily, I give up.]

Ultrasounds in Women of Size - General Information

Ultrasounds in women of size can be more difficult to do than in women of average size, but most of the time they are quite doable and most women of size get an adequate ultrasound result. 

It is true that extra adipose tissue on the abdomen CAN make it harder to get a completely accurate ultrasound "picture" so the task is definitely harder in fat women. Because of this, it is possible to sometimes "miss" a problem in women of size that might be caught in a smaller woman.  In particular, research shows that it is particularly difficult to get complete evaluations of the fetal heart in women of size. To a lesser degree, there can be difficulties with visualizing the fetal spine, the cranio-facial system, the fetal kidneys/urinary system, and the mother's ovaries.

Therefore, it's not uncommon for the ultrasound report to note the mother's obesity and whether there were any problems completely visualizing anything.  Don't take such comments personally; it's simply CYA for the ultrasonographer, in case something turns up later that was not noted in the ultrasound report.

Simply noting adiposity on a report is not fat-phobia; it's for liability purposes, not to make you feel badly.  However, berating you about your fatness, telling you that they'll never get a decent picture because you are so fat, or treating you roughly with the justification that it's "harder" to get good images because of your fatness is fat-phobic treatment. 

It's not just what they say, but how they say it, the intent behind saying it, and how they treat you.  Most women of size have unremarkable ultrasound experiences, but now and then some do experience fat-phobic treatment and that is never acceptable.

Transvaginal vs. Transabdominal Ultrasounds

There are two methods typically used for ultrasound in pregnancy:

• Transvaginal ultrasound
• Transabdominal ultrasound

In the beginning of pregnancy, fetal structures are particularly difficult to see via abdominal ultrasound in most women, regardless of size, so most women have transvaginal procedures if they have ultrasounds in their first trimester. 

To do a transvaginal ultrasound, doctors take a long cylindrical ultrasound transducer, cover it with a condom, and put it inside the woman's vagina where they can move it around as needed. This gets the ultrasound closer to the fetus, there is less intervening tissue to impede transmission, and it therefore improves the quality of the images.

Transvaginal ultrasounds are common in the first trimester of pregnancy in women of all sizes.  They are usually done in order to date the pregnancy more accurately and/or to tell if the pregnancy is viable.

In the second trimester, doctors usually switch to transabominal ultrasounds in most patients, which are commonly used to look for any problems with fetal structure (birth defects) and to check placental placement.

However, because it is more difficult to visualize the fetus adequately in women of size, doctors may still need to use transvaginal ultrasounds in women of size early in the second trimester (especially women with a lot of abdominal adiposity) in order to get a clearer picture.  By the end of the second trimester, however, doctors are usually able to get adequate images via transabdominal ultrasounds, even in women of very large size.

These are the main differences between ultrasound in women of average size and women of increased size. However, most of the time, reasonably adequate images are obtained and the procedure is very similar, regardless of size.

Possible Problems To Be Aware Of

Although ultrasounds usually go just fine with women of size, there are some possible problems to be aware of.  The first we already discussed; doctors may need to use transvaginal ultrasounds longer in women of size, and the quality of images can be decreased, regardless of the method.

Another problem women of size sometimes encounter is that doctors and ultrasound technicians may press extra hard on women of size to try and compensate for less-clear images. (This has happened to me...ouch!)

Sometimes pressing firmly does help get a better image, but pressing extremely hard can also cause more problems than it solves by distorting the image that they do get.  There have been women of size who have been misdiagnosed with birth defects due to the ultrasound tech pressing too hard.

One woman wrote to me about her experience with this; the ultrasound tech pressed extremely hard, despite her protestations, and they got a devastating diagnosis.

Jessica's Story (paraphrased): I had an ultrasound at 18 weeks. I was told my weight made it impossible to scan the baby, and they saw encephaly [Kmom note: Hydrocephaly?] on the scan. They told me he was going to have a grossly misshapen head and that I'd need a c-section. They sent me to a high-risk OB. He saw the scan and said, "Wait a minute, you're pushing too hard! Do a vaginal!" They did the vaginal and there was our rascal, safe and sound, the right size, and no deformity. I was sore for a week after the abdominal scan, the transducer hurt so bad.

What happens when they push too hard is they distort and add artifact to what they can't see, and the baby looks deformed to their measurements.

If you are told that your baby has deformities or other problems based on an ultrasound scan and they seemed to be pushing pretty hard, ask for the scan to be repeated with a transvaginal scan or by a perinatologist (who usually has the most advanced equipment). Although it is uncommon for images to be distorted from too-strong pressure, it has happened, and should be ruled out as a cause before making a final diagnosis.

Although more firm pressure may be needed on women of size, you should NOT have to endure pain during an ultrasound. If you experience this problem, let the tech know that he/she is hurting you. Let them know that you realize that doing an ultrasound on a heavy person can be more difficult, but suggest that they try more gently at first and only increase pressure if needed. Remind them that if the results they get are suboptimal, there is always the option of a transvaginal ultrasound instead. If they don't listen, then end the session and ask for another session at another time with someone who will listen to and respect your concerns and discomfort.

Improving Image Quality in Women of Size

If your doctor or ultrasound tech is having difficulty getting an adequate image on you, there are several ways to improve image quality in a woman of size. 

For example, often just coming back for another ultrasound in a few weeks is enough to "see" everything more clearly. The baby is older, the uterus has lifted up out of the pelvis a bit more, and the baby may be in a better position the second time. These factors can be very important. 

Research shows that just waiting a few weeks is usually enough to get adequate ultrasounds in most women of size.  Probably the best alternative is simply to wait until 18-20 weeks to do an ultrasound at all in women of size, since after that point, most scans are able to get adequate results. 

Requesting that a follow-up ultrasound be done on a more powerful machine in a center that specializes in prenatal ultrasound may also improve results as well. Not all ultrasound machines are of equal quality; the ones in a doctor's office tend to be the least effective.  Furthermore, it can be very helpful to see someone who specializes in prenatal ultrasound for a living, because they often have the best skills in how to elicit clearer images. 

There are also several other refinements that can be done if the technician has difficulty resolving the images adequately. First, if you have a large "apron" (saggy belly), pull it up and hold it back so the transducer can go underneath/below it. This reduces the amount of adipose tissue the transducer has to go through and can therefore improve the image.  Don't be embarrassed if you are asked to do this; your body is simply your body, lots of people of all sizes have droops and sags in various bits, and it's not that uncommon in diagnostic tests to have to pull and push things this way and that a bit. Be matter-of-fact about it and just do it. It really can help.

Turning on your side and putting the transducer on the side may also help clarify the images, especially if the baby's position is less than optimal, or if there are multiple babies inside.

Another technique they can use to clarify images later in pregnancy is to put a vaginal transducer inside your belly button. Some research has reported success with this, especially with visualizing the fetal heart.

Rosenberg (1995) reported on their experience using transvaginal probes in the belly buttons of obese women to help improve ultrasound resolution. 19 of the 25 cases involved incomplete imaging of the fetal heart. Techs filled the women's belly buttons with ultrasound transmission gel, and then a transvaginal probe was inserted into the belly button. This improved image resolution and resulted in satisfactory heart images in 18 of the 19 women with incomplete fetal cardiac reports. All told, 24 of the 25 heavy women (96%) were able to have a 'complete fetal survey' using this technique.

Remember also that not all problems with ultrasound imaging result from fatness.  If the baby is in a poor position or if the placenta is anterior (in the front), this can decrease the accuracy and clarity of the images.  Technician skill and the power of the ultrasound machine can also impact results.

So although it's true that ultrasound accuracy is definitely lessened in women of size as a group, it's difficult to know whether the problem in any particular scan is due to adiposity or any one of many other factors.  Don't take it as a personal indictment if there is a problem with your scan; be aware of the possible problems, know the possible fixes, and consider trying again in a few weeks if you feel it's really important to have a complete scan. 

Coming Soon: Do Women of Size NEED Extra Ultrasound Scans? What are the pros and cons of having ultrasounds?

Healthy Birth Practices: Keep Baby With You

We've been discussing the Six Lamaze Healthy Birth Practices.

This is the last in a series on the Lamaze Healthy Birth Practices, why they are important in birth, and how they are less commonly "allowed" in women of size. The previous entries have been:

1. Let Labor Begin On Its Own
2. Walk, Move Around, and Change Positions During Birth
3. Bring a Loved One, Friend, or Doula for Continuous Support
4. Avoid Unnecessary Interventions
5. Get upright and follow urges to push

And the final Healthy Birth Practice is [drumrollllllllllll] :

6. Keep baby with you

Although you'd think that this one was a no-brainer, it's surprising how many women are kept from early and frequent contact with their babies after birth, which then can impact bonding and breastfeeding. 

And because of the incredibly high rate of interventions used with "obese" women, women of size often have even less contact with their babies after birth, which strongly contributes to lower rates of breastfeeding in this group.

Why Skin-To-Skin Contact and Rooming In Is Important

You wouldn't think you would have to fight for contact with your baby after birth, but sadly, mothers and babies are separated far too often postpartum and it can have long-lasting consequences on breastfeeding and bonding.

This separation seems to happen even more in high-tech, high-intervention births, especially cesareans.  Breastfeeding initiation rates are lower in women who have had cesareans, skin-to-skin contact is often not available (even though it could be), and contact is often delayed, sometimes for hours or even longer. In the meantime, babies are often given pacifiers and bottles of formula or glucose water, which decrease the baby's desire to nurse and which often interfere with a good latch. 

Even when the baby is born vaginally, the mother often gets only a few moments with baby before it is whisked off, cleaned up, weighed and measured, examined, given eye goop, and then bundled into a blanket.  When the mother gets the baby back, no skin-to-skin contact is available anymore and critical early moments together have been missed. In addition, many mothers are discouraged from having their babies "room in" with them at night, yet frequent nursing at night is very important in establishing a good milk supply.

Research shows that early skin-to-skin contact and continuous time (rooming in) with the mother improve outcomes.  Babies sustain their temperature better when skin-to-skin with their mothers, they maintain higher and better blood sugar, and have better cardio-respiratory function.  Skin-to-skin contact decreases crying behaviors, increases maternal gestures of affection, and long-term bonding seems improved after rooming in.  In addition, both short-term and long-term breastfeeding rates are improved with skin-to-skin contact and rooming in.Yet hospital routines often get in the way of this important time.

One study in Pediatrics in 2008 looked at six "Baby-Friendly" practices to see which were associated with less cessation of breastfeeding before 6 weeks. These "baby-friendly practices" included:

• Breastfeeding initiation within 1 hour of birth
• Giving only breast milk
• Rooming in
• Breastfeeding on demand
• No pacifiers
• Fostering breastfeeding support groups

Sounds pretty basic, right?  Not so.  Only 8.1% of the mothers in the study experienced all 6 "Baby-Friendly" practices.  According to the study (my emphasis):

The practices most consistently associated with breastfeeding beyond 6 weeks were initiation within 1 hour of birth, giving only breast milk, and not using pacifiers. Bringing the infant to the room for feeding at night if not rooming in and not giving pain medications to the mother during delivery were also protective against early breastfeeding termination. Compared with the mothers who experienced all 6 "Baby-Friendly" practices, mothers who experienced none were approximately 13 times more likely to stop breastfeeding early.

Interventions, Women of Size, and Impact On Breastfeeding

These practices may be even more important in women of size.  Research shows that there is a lower rate of breastfeeding among "obese" mothers. Some of this may be because of legitimate supply issues from PolyCystic Ovarian Syndrome (PCOS), a metabolic disease that many fat women have.  Other factors that may impede breastfeeding establishment include possible subclinical hypothyroidism, subtle or overt discouragement of breastfeeding in women with large breasts, more difficult mechanics with a larger body, or postpartum anemia.  [More on this in a future post.]

However, the role of aggressive birth interventions in the lower rate of breastfeeding among obese women typically goes conveniently unexamined in the research. Breastfeeding failure is blamed solely on fatness, when in fact, the high level of interventions in obese pregnancies and births may also play a significant role.

For example, "obese" women are induced at a higher rate than women of average size, with most induced women receiving pitocin at some point in labor.  Pitocin is an anti-diuretic, and when combined with aggressive IV fluids, can cause significant edema in the mother.  This can cause greater breast engorgement and make it difficult for the baby to latch on and nurse efficiently.

A high rate of inductions usually means a high rate of pain medication use in the mother, and some research indicates that more pain meds results in impaired breastfeeding behaviors in the baby, especially with IV narcotics. In particular, some research shows that the combination of pain meds and separation of mother and baby after birth significantly inhibits initial breastfeeding behaviors, while other research shows that avoiding pain medications in labor is protective against early breastfeeding cessation.

Because the rate of cesareans in women of size is so high, it also has strong impact on breastfeeding rates. Research shows that lactogenesis (the mother's milk "coming in") can be delayed after a cesarean compared to a vaginal birth.  This may be due to some inherent hormonal differences between vaginal birth and cesareans, or it may be due to decreased immediate contact after birth. Delayed initiation of breastfeeding may also be a factor; research shows that in women delivered by cesarean, aggressive early suckling leads to better breastfeeding rates than delayed suckling. 

Another possible reason for breastfeeding difficulties in fat women is the excessive intervention commonly seen with big babies, which are more common in women of size. Big babies have a higher risk of low blood sugar after birth, so there is often aggressive testing and formula supplementation of these babies after they are born, but all the separation, testing, and supplements can end up further sabotaging breastfeeding.

Research shows that most of the time routine testing and supplementing is not necessary in big babies if the baby is not symptomatic and is nursing well.  Furthermore, as noted above, skin-to-skin contact has been shown to improve blood sugar rates and stability of babies after birth, so the common interruption of time between women of size and their babies is usually unnecessary.

The high rate of interventions commonly used in the births of "obese" women often leads to a "perfect storm" of conditions that inhibit neonatal adaptations to life outside the womb, and interfere with bonding and breastfeeding in babies of women of size. 

Alas, my own first birth was a good demonstration of the negative effects of such interventions on breastfeeding. 

My Experience

Breastfeeding came very close to "failing" with my first child....for all the reasons cited above.

The doctor feared a big baby, so he induced labor. Labor was long and hard, high doses of pitocin and IV fluids were pushed, and pain meds were eventually needed. The induction failed, and we ended with an extremely traumatic cesarean. 

After the cesarean itself, there was no skin-to-skin contact, and only a brief moment of bonding in the post-op recovery room, after which I was separated from my baby for EIGHT HOURS. By the time we tried nursing, she had had many bottles of formula, glucose water, and had been regularly given a pacifier.

Even after I started breastfeeding her, the nurses pushed more bottles of glucose water to "flush out the jaundice" (jaundice is a common side-effect of pitocin). Never mind that glucose water doesn't flush anything and actually prolongs or worsens jaundice.

I experienced massive fluid overload postpartum because of the anti-diuretic properties of pitocin combined with an over-zealous IV protocol. I had severe edema everywhere, including my breasts. That made it very difficult for baby to latch on, and baby was very sleepy from the jaundice caused by all the pitocin. This made breastfeeding very inefficient even when it did happen.

I had a long, stressful labor and a horrible cesarean experience. A cesarean plus a stressful labor can cause real problems with lactogenesis. My milk didn't come in for a week....and when it did come in, the baby could hardly latch on because I was so severely engorged.  Add into that her sleepiness, all the formula and glucose water, all the resultant infrequent nursing....and you have a classic recipe for delayed lactogenesis and breastfeeding issues.

So was the problem here really my fatness? Or was it all the interventions that I experienced because of the way the doctors treated my fatness, interventions that snowballed into the classic cascade of complications?

I did eventually manage to preserve the breastfeeding relationship, but mostly through sheer luck and stubborness. But it took about 2-3 months before things really started to work, and I almost gave up any number of times.

I should also note that I never had problems again with breastfeeding in my subsequent pregnancies. If fatness was really to blame, the problems with breastfeeding would have been consistent.  Instead, the difference was in the interventions used and my insistence on early and frequent nursing, rooming in, and constant contact with my babies.  For me, that made all the difference in the world.

What Can You Do To Avoid This?

While there may definitely be something to the idea of hormonal imbalances like PCOS causing breastfeeding issues, it is important not to overlook the negative influence of the aggressive interventions commonly used in women of size. These can also affect breastfeeding, but are rarely controlled for in most research.

For fat women to have the best possible chance to succeed at breastfeeding, the best approach is to:

• promote a vaginal birth with spontaneous labor
• not use routine birth interventions unless truly medically indicated, especially IV fluids and pitocin
• encourage early contact and breastfeeding as soon as possible after birth
• avoid separations between mother and baby
• promote skin-to-skin contact as much as possible and as early as possible
• have the baby "room in" after the birth, and especially at night
• avoid routine neonatal testing for low blood sugar unless baby is symptomatic
• strongly discourage formula and sugar-water supplementations unless necessary
• encourage frequent breastfeeding (every 2 hours or more)
• give help and information about positioning to women with very large breasts
• provide strong encouragement for breastfeeding to women of size

Of all these recommendations, I think the most important are to breastfeed early as possible, as often as possible, and to avoid separations whenever possible.

Some women of size may still experience breastfeeding problems--even when they do everything "right"--because of the hormonal imbalances that PCOS can cause. However, that doesn't mean that breastfeeding should be discontinued or discouraged, because any amount of breastmilk a baby receives is extremely beneficial immunologically.

Instead, these women should be given information and support for increasing milk supply through the use of herbs and medications if needed, they should be given emotional support while working on breastfeeding issues, they should be given information and support for improving baby's latch (craniosacral therapy can work wonders in some babies), and they should be provided information about supplementation alternatives like Lact-Aid or the Supplemental Nursing System if the addition of formula is needed.

Of course, sometimes weaning is the only sane thing to do under certain circumstances, and it deserves to be grieved and accepted if that becomes necessary.  But too often, women are not told that breastfeeding does not have to be an all-or-nothing proposition. Many women who experience problems can breastfeed at least partially, short-term or long-term, thereby giving baby much-needed immunological protections while still providing formula supplements if necessary.

But most of the time, most women can breastfeed, and more would probably breastfeed successfully if there were fewer interventions routinely used around labor and birth, if early skin-to-skin contact were uniformly utilized, if early and frequent breastfeeding was encouraged, if better breastfeeding support were given after birth, and if rooming-in became the standard of care. 



Question: How many of the "Baby-Friendly" practices (breastfeeding initiation within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, breastfeeding support groups) did you experience with your babies?

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.

Obesity Stigma Not Helpful - No, Really?

This just out!!  Obesity stigma harms more than helps!! 

[No, really????]  

Amazing they have to have an actual research journal article debating this.  Isn't it obvious?  Well, evidently not, sigh. 

I suppose I should be grateful that someone is taking time to disprove the kinds of lame claims that more stigma is needed, not less. 

On the flip side, though, is that while they are concerned about the negative effects of obesity stigma on fat people, the big concern is that this stigma gets in the way of obesity intervention efforts. 

I know these authors have good intentions, but I don't think they quite get it, do you?  Pretty typical of the Rudd Center, I gather.

But at least they are saying something against obesity stigma and countering the usual nonsense out there. It just amazes me that some idiots can actually believe that obesity stigma is really an effective tool for health improvement.

Here's the abstract of the study.  [Obviously, emphasis mine.]


Obesity stigma: important considerations for public health.

Am J Public Health. 2010 Jun;100(6):1019-28. Epub 2010 Jan 14.
Puhl RM, Heuer CA.
Director of Research and Weight Stigma Initiatives, Rudd Center for Food Policy and Obesity, Yale University, 309 Edwards St, New Haven, CT 06520-8369, USA.

Abstract

Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. Despite decades of science documenting weight stigma, its public health implications are widely ignored.

Instead, obese persons are blamed for their weight, with common perceptions that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. We examine evidence to address these assumptions and discuss their public health implications.

On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity.

Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.

These findings highlight weight stigma as both a social justice issue and a priority for public health.

PubMedID: 20075322