A Peek Into The Future?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



Study Abstract

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

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

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

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

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

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

PMID: 21381881

New Facebook Resource for Big Moms

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

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

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

Here is an excerpt their blurb:

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

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

ICAN Conference Next Week

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

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

Here is a quote from an article about the conference:

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

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

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

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

ICAN’s Mission Statement

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

ICAN’s Vision Statement

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

ICAN’s Statement of Beliefs

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

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

Hope to see you at the conference!

Belly Blog Carnival Deadline Extended

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

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

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

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

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

Know Your Demographics, Stores!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

COME ON RETAILERS.  KNOW YOUR DEMOGRAPHICS! 

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

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

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

Are You Ready?

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

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

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

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

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

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

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

Why Make a Readiness Kit?

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

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

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

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

Take It In Baby Steps If Needed

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

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

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

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

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

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

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

Conclusion

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

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

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

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

Belly Blog Carnival!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bring on the bellies!!

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

Further Belly Thoughts

About a month ago, I published a post called Belly Thoughts that was quite controversial to some people. 

I've been writing a follow-up for a while, but I've been working on a big project at work and have had sick/injured kids, so I have had a hard time finishing it. I have also been struggling to clarify my dismay and surprise over people's response to that post. Honestly, the response upset me and I thought it best to wait a bit before replying so I could make a more measured response.

But I think it's time now to continue the discussion.  Forgive me if it's a bit rambly.  It's just time to get it out there, imperfect as it is, so we can discuss it and then move on.

Trigger Warning: Frank discussion of body image issues and body ambivalence will follow.

First, thank you to those who commented, even if I didn't agree with you or like what you said.  Dialogue is important and it's not always a bad thing to hear dissenting voices.  It generates discussion and can clarify issues or further the conversation. Obviously, this topic provokes some strong feelings, and I think that's an important point to explore. 

One complaint that was made was that the post needed a Trigger Warning.  With some reflection, I can see that point. I thought about putting one in the original post, but I thought it was not needed because I felt I was pretty clear in the intro paragraphs what was going to be in the post.  However, I can appreciate that some people in their journey need a really clear and obvious warning about these things. So that point is noted and I have already gone back and added a trigger warning to the original post and to this one as well.  My apologies to anyone who I inadvertently triggered.

Some folks objected to the Shamu word. That may have been a bad choice, but I was actually being ironic, and I think folks missed that. I see people on the feed mockingly use words commonly used to deride us (like "deathfat" etc.), so that's where I was going with Shamu, but the ironic intent may not have been clear enough. I was trying to point out the tremendous irony of worrying about what I'd look like at 9 months pregnant and then not looking pregnant at all. By using the term Shamu, I thought it made for a better, more pointed bit of irony. But alas, I think the term is so emotionally loaded for some that they didn't see an ironic use of it. I'm sorry it caused bad feelings for some.

One thing I think it's important to clarify is that what I was talking about was body ambivalence, not body loathing.  No, I don't always have perfectly happy loving feelings towards every part of my body 24/7 (who does?), but sharing that does not mean that I hate my body or am engaged in fat-based self-loathing. It only means that I have mixed feelings towards parts of my body sometimes.  It doesn't mean that I don't have good feelings towards my fat body at times, or that I've been hiding secret loathing behind a facade of fat acceptance.  It's just body ambivalence, not body hatred.

Perhaps I wasn't clear enough in the post that most of the time, I'm pretty at peace with my body ─ a lot more than a lot of the thinner women I see around me, in fact.  But not 24/7/365, and some parts are more challenging to love than others, you know?  I was just trying to be up front about that, because I think we NEED more of this kind of honesty, especially among mothers, and especially among mothers of size.  But it wasn't about hating myself, just my struggle to love the changes that pregnancy has wrought.

Before pregnancy, my most difficult part to love was my chest, because I'm very well-endowed and that has all kinds of physical and emotional burdens attached.  After pregnancy, once breastfeeding worked out, that actually was the part that experienced the most positive self-image improvement.  The part of me that had previously only been a burden before suddenly was responsible for nourishing and protecting my babies for  months ─ years ─ on end, and my babies certainly loved that part of me, so why couldn't I?  I just had a totally different take on my breasts after that, even as I still sometimes struggle with loving them fully.

My belly was a different matter, much to my surprise.  Before pregnancy, I was pretty much fine with my belly.  But I was really surprised how much challenge I had with it during and after my pregnancies ─ especially after multiple pregnancies.  It does take a toll on your body shape and your body image, and I was just trying to articulate how that challenged me in my fat-acceptance and body-acceptance process.

So folks, if you were worried about me loathing my body or that I was suddenly revealing secret reservoirs of self-hate, please be reassured that most of the time, I'm pretty self-accepting.  But I don't think it's a problem to share that I'm not always that way, or that certain things really challenge my body image more than others.  I think a combination of pregnancy and recent aging-related changes of perimenopause gave rise to more reflection than usual on that, that's all. 

One thing I was very much troubled by was the fact that some folks questioned whether my posts belonged on the Fatosphere.  That in particular really shocked me, considering all the work I've done in Fat-Acceptance over the years.  Heck, I've been in the Fat-Acceptance movement for longer than some of my readers have been alive.  I'm not just talking the talk, but have been actually walking the walk for many years, and have been writing, researching, publishing, and presenting at conferences on the topic of fatness and pregnancy for more than a decade.  I've been a quite vocal and active FA-advocate, and have been a member of NAAFA for years.  To be questioned in my own backyard about my "FA-ness" was quite distressing.

Let me be clear.  I don't see my post as contrary to the purpose of the feed at all, or to Fat Acceptance in general. The Fatosphere is SUPPOSED to be a place where we can work through a lot of our feelings, good and bad, about our bodies. In my view, it's not a "you can only express positive things about your body no matter what" place.

Certainly, I surely see a lot of body ambivalence on other blogs. Why would my blog be exempt from being able to talk about that? The fatosphere is supposed to be the one place where we CAN talk about these things without being judged. And yet, there I was, being judged for some pretty normal feelings, ones extremely common to mothers after pregnancy, and I wanted to talk about how that interacted with my self-acceptance beliefs. I see that as very much in concordance with what the Fatosphere is supposed to be about.

I'm also very frustrated with the idea that I can't express ambivalence about the droopy baby belly, the "flap" if you will. Nearly all mothers have some ambivalence about this ─ it's very normal in women of all sizes, and I think it's intensified for many women of size. Why is this okay for women of average size to talk about ─ but not for us as women of size?  We all have to process it; it's a very normal feeling.  Some people experience the belly flap more than others, but we all have to process body changes to some degree.

It's not like because we are fat-accepting, we have a magic shield against negative feelings from body changes.  We have these issues too, and it may be intensified in those with previous body image issues.  Even those of us who are pretty far along on the fat-acceptance spectrum can still feel challenged by these things ─ and that's okay. And it doesn't mean that we are now body-haters and full of self-loathing and about to sign up for surgery.  It means we're processing normal feelings.

My whole point is that the changes in my body (and specifically my belly) resulting from several pregnancies, lipedema, and age are challenging my fat- and self-acceptance in a way it's not been challenged in a long time, and I continue to struggle with that. I think being honest about these kinds of struggles is absolutely VITAL to the fat-acceptance discussion. What are we here for if we can't discuss that kind of thing?

I'm not telling others how THEY should feel about their bellies. If you came through pregnancy perfectly positive about your belly, more power to you. I'm simply trying to express that even in me, a VERY self-accepting and fat-accepting person, dealing with this pregnancy after-effect has been quite challenging, even years after my last pregnancy, and how surprising this has been to me as an activist.

I certainly think that postpartum feelings about your body (and the unique challenges that might bring to fat women) is an appropriate topic for my blog, don't you? I KNOW a lot of other women of size have struggled with the same feelings because they've written me about it. I was articulating my own struggles as a way to not only help me with my own ambivalence, but to help others explore their own.

It was such a shock to me, how pregnancy challenged my fat-acceptance in so many ways. For example, as I've written about before, I went from a take-no-guff-from-doctors FA person to a meek little sheeple who got railroaded and frightened into a whole bunch of unneeded and fat-phobic interventions in my first pregnancy. It took me quite a while to get past that, but working through that and empowering myself enough to question the doctors led me to create my website and my blog. The journey was worth it ─ but it didn't happen overnight, and it took a lot of emotional processing to get there.  Sharing that is helpful to other fat women struggling to figure out what interventions are needed in their pregnancies and which ones are questionable,  what choices they really have in birth, and cutting through the anti-fat rhetoric that surrounds so much of the information out there on pregnancy and fatness.

I think a similar journey is worth it on the whole belly ambivalence question too. Pregnancy (and especially post-partum) totally challenged my FA-ness, and I still work through it. I don't think talking about that is in opposition to the fatosphere at all. I think it will help other women on their journey, which is why I talked about it in the first place. People are at all different points on their journey to fat acceptance, and I think it's extremely helpful to see someone else struggle with that journey too. To have my FA credentials questioned because of that is extremely frustrating to me.

Another thing that frustrated me was that while I discussed my belly ambivalence very frankly, I also made a real point of bringing the question back to positiveness at the end of my post. I made a point of honoring our bellies anyhow, even in the face of ambivalence, and acknowledging the incredible work they did. I thought I made that point pretty strongly, using my words and my belly-painting pictures, because it's very much how I feel. So it's upsetting to me to have that conclusion ignored or negated. Yes, I talked frankly about belly ambivalence and the challenges I've experienced, but then I brought the discussion back to a positive conclusion. That's an important point that got ignored by some.

Furthermore, it makes me frustrated to feel censored in what I'm "allowed" to talk about as a "good" fattie. Ambivalent feelings are part and parcel of the journey to FA, even for people well along on that journey. Other people can talk about this on the feed (and do), but for some reason it created a lot of reaction when I did it. Perhaps it's harder to hear it in relationship to pregnancy (society really tends to discourage expressing negative or ambivalent feelings about pregnancy).  Or perhaps it's hard to hear someone who doesn't usually express much body-ambivalence actually express some.

But the whole point was that this is a NORMAL and VERY COMMON response to pregnancy and post-partum body image in women of all sizes, and that it's often intensified for women of size and we should be discussing that.

Expressing that doesn't make someone anti-FA. It just acknowledges a common feeling among many women of size, something many of the women in the comments commiserated with, you'll note.

The fall-out from all this is that right now, I don't feel safe choosing topics for the blog, and that alarms me. I was planning a big series addressing the risks of pregnancy in women of size, because the fat-phobic doctors contend that a pollyanna approach ("everything will be fine") to fatness and pregnancy is misleading and intellectually dishonest. Research is clear that there are more risks for certain complications in women of size in pregnancy ─ the problem is that doctors DISTORT that information and use it as a scare tactic or a way to pressure women into questionable interventions. I want my series to look at the research dispassionately, acknowledge what risks there are, make sure people understand these potential risks, discuss how we can be proactive to lessen those risks, and make sure people understand that, though there, these risks are still generally small ─ that most fat women will have healthy babies just fine.

But now I'm questioning whether I should even attempt such a series, whether this will be seen as too negative or not "FA enough" for some. Yet I think not doing that series would be a tremendous disservice to women of size.  The whole purpose of my website and my blog is honest and accurate information, not just rah-rah cheerleading and a polyanna approach.

Women of size NEED intellectually honest discussions about the research, good and bad, along with primers for understanding it and using it to help improve our outcomes and experiences.  We don't need more "everything will be just fine" or "oh my God you're going to die" extremism.  We need a more nuanced approach.

I just am frustrated with the idea that we should only be fat cheerleaders and never be allowed to go beyond that.  Fat Acceptance is a journey, and I think it's important that we be allowed to fully process our feelings, even the ambivalent ones, along the way, without people jumping to conclusions about our FA-ness. 

Okay, so now I've vented a bit and expressed my concerns too.  Feel free to discuss in the comments section.  Just please be respectful and polite, even if you disagree and need to argue a point, okay?  I'm feeling particularly tender and touchy on this subject right now and would appreciate some delicacy, even as I know that dialogue is important.

But I don't think the discussion ends here.  This is of necessity a rather negative post, and I'm okay with that up to a point.  I think the frustrations needed to be aired and perhaps some good will come of the dialogue.

However, I prefer to bring the discussion back to the positive whenever possible.  So I decided to put the negative things in this post and do a whole different post next time that focuses things a little differently, a little more positively without being false, that puts things back on a more constructive footing. 

I'd like to propose a Belly Blog Carnival next time ─ more on that soon!!

“You Are Short Of Breath Because You Are Overweight”

Another "gem" from My OB Said WHAT?!?"

“You are short of breath because you are overweight.” – Doctor to a mother a few days after birth. One week later she was treated for pulmonary embolisms.

This is a particularly frustrating example of weight bias in medicine.  This was a woman who had recently had a cesarean, and had a documented family history of blood clots, and the doctor still dismissed her shortness of breath ─ a classic symptom of a blood clot that has traveled to the lungs (pulmonary embolism) ─ as being due to her weight alone. 

Because, you know, nothing else could possibly be wrong with a fat person except fatness.

So obviously, the main lesson here is that doctors need to stop blaming fatness for everything and be alert to the possibility of other complications when a symptom presents.

But another cautionary side note to this tale is how important it is to lower the cesarean rate in women of size.

One reason that the high cesarean rate in women of size is so dangerous is the risk of blood clots like these.  Blood clots are a rare but extremely serious complication of any kind of surgery; do enough surgery, and the rate of life-threatening blood clots like these will rise significantly. 

Remember, pregnancy increases the risks of blood clots in women of all sizes already, and "obesity" increases your risks for blood clots a bit more on top of that.  Then add into that major surgery ─ and cesarean rates of nearly 50% (or more) in some hospitals for "obese" women ─ and blood clots afterwards will be seen more and more often.

Mind, it's still a fairly rare occurrence, but it can ─ and does ─ kill.  Yet it's one risk doctors can proactively prevent much of the time by making sure that only truly needed cesareans are done in women of size, and when a cesarean is truly indicated, by considering the pros and cons of a blood thinner in that situation.

[Side note: If you are a person of size and have surgery planned, you should discuss the pros and cons of blood thinners with your surgeon ahead of time, especially if you have a clotting disorder or any family history of blood clots, strokes, or heart attacks.  It's not always a clear-cut decision; there are benefits and risks to the use of blood thinners.  However, you might want to discuss ahead of time the pros and cons of them for your particular situation.]

Furthermore, doctors should have a high index of suspicion for possible pulmonary embolism in an "obese" woman who has just had a cesarean, let alone one with a family history of blood clots.
This mother told her doctor about her symptoms a few days after the birth, and despite her recent cesarean, her size, and her family history of blood clots, the doctor dismissed her symptoms and told her the problem was because she was overweight.  She was sent home.

She lived with that blood clot for more than a week and is lucky she didn't die.  She was fortunate that she was seen by 2 visiting nurses postpartum, who recognized a strong possibility of a blood clot to the lungs and sent her to a hospital.   The emergency room took it seriously, did the testing needed to diagnose a pulmonary embolism, and got her to intensive care right away.

From her acccount, things were a bit touch-and-go for a while, but she did survive.  However, she was separated from her newborn baby for two weeks (any mother who has been separated from her newborn for any amount of time knows just how heartbreaking that is!) and had to stop breastfeeding.  This doctor's dismissal of her symptoms cost her a lot, emotionally and physically. 

(Fortunately, she was able to re-establish breastfeeding eventually, but many times breastfeeding doesn't survive a separation like that.)

This is yet another example of the common problem of doctors missing serious health problems in fat people because they are so busy blaming every health complaint on fatness. As if nothing else could ever be wrong!

More Proof of Failure to Wait

We've talked before about recent research that indicates that many cesareans are performed for "failure to wait" ─ that is, doctors jump to a cesarean too soon, when waiting a bit longer might well have avoided the cesarean alttogether. 

We know that far too many inductions are happening, and that inductions on a first-time mom or a mom with an unripe cervix raises the risk of cesarean substantially.  Here's yet more proof that, when done, far too many inductions are given up on too soon, and that a tincture of patience can often make a world of difference.

But of course, better yet to avoid inductions entirely that are not truly medically indicated.


Obstet Gynecol. 2011 Feb;117(2, Part 1):267-272. Failed Labor Induction: Toward an Objective Diagnosis.

Rouse DJ, Weiner SJ, Bloom SL, Varner MW, Spong CY, Ramin SM, Caritis SN, Grobman WA, Sorokin Y, Sciscione A, Carpenter MW, Mercer BM, Thorp JM Jr, Malone FD, Harper M, Iams JD, Anderson GD; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU).

Abstract

OBJECTIVE: To evaluate maternal and perinatal outcomes in women undergoing labor induction with an unfavorable cervix according to duration of oxytocin administration in the latent phase of labor after ruptured membranes.

METHODS: This was a secondary analysis of a randomized multicenter trial in which all cervical examinations from admission were recorded. Inclusion criteria: nulliparas at or beyond 36 weeks of gestation undergoing induction with a cervix of 2 cm or less dilated and less than completely effaced. The latent phase of labor was defined as ending at a cervical dilation of 4 cm and effacement of at least 90%, or at a cervical dilation of 5 cm regardless of effacement.

RESULTS: A total of 1,347 women were analyzed. The overall vaginal delivery rate was 63.2%. Most women had exited the latent phase after 6 hours of oxytocin and membrane rupture (n=939; 69.7%); only 5% remained in the latent phase after 12 hours. The longer the latent phase, the lower the vaginal delivery rate. Even so, 39.4% of the 71 women who remained in the latent phase after 12 hours of oxytocin and membrane rupture were delivered vaginally. Chorioamnionitis, endometritis, or both, and uterine atony were the only maternal adverse outcomes related to latent-phase duration: adjusted odds ratios (95% confidence intervals) of 1.12 (1.07, 1.17) and 1.13 (1.06, 1.19), respectively, for each additional hour. Neonatal outcomes were not related to latent-phase duration.

CONCLUSION: Almost 40% of the women who remained in the latent phase after 12 hours of oxytocin and membrane rupture were delivered vaginally. Therefore, it is reasonable to avoid deeming labor induction a failure in the latent phase until oxytocin has been administered for at least 12 hours after membrane rupture.

PMID: 21252738

Belly Thoughts

So, for those of you who have been pregnant, how did you feel about your pregnant belly?  How did you feel during pregnancy?  After pregnancy, with the post-mummy tummy?  Years later?

I was reflecting the other day on my relationship to my belly, especially in regards to my pregnancies and births ─ how I've celebrated it in some ways, and how I've struggled with it in other ways. 

I thought about things that I expected to happen and how the reality did or didn't meet those expectations, things that surprised me, things that pleased me, and things that made me unhappy or which challenged my peace with my body. 

Thought I'd share some of those thoughts here.  Hope you will share your own experiences too.

Trigger Warning:  Frank talk about body ambivalence and negativity. Some folks may find this post challenging or triggering and may want to opt out.


Worrying About Shamu

My first pregnancy was a surprise.  I went from being told I would not be able to get pregnant without "help" to being pregnant a few months later without trying.  So I was totally not prepared to think about pregnancy bellies! 

I hate to say it now because it sounds so vain, but I was really worried about what I'd look like pregnant.  I was already a large person; I figured when I was pregnant I'd look like Shamu. 

Now, I don't mean that in a negative way; I was pretty at peace with my body pre-pregnancy, and I didn't really "fear" being huge in pregnancy.  But I was having a hard time picturing the giant basketball belly you see on skinny women added to my already sizable frame, you know?  And I wondered what I'd be wearing on that basketball belly (or if I could find anything to wear at all, considering that it wasn't easy to find clothes even when not pregnant).

I know a lot of other women of size wonder these things too, because the top post viewed on this blog (by a HUGE margin) is the one on plus-sized pregnancy photos.  There are so few pictures of women of size out in the media, let alone pregnant women of size.  (And fat pregnant women of color?  Nearly impossible to find. Gah!)

The most common search words people use when they find my blog has to do with this search for images of fat pregnant women.  Except the phrases are usually "overweight and pregnant photos" or "obese pregnant belly" or "obese pregnancy pictures" or "plus-size pregnancy belly pics" and things like that.  There is a tremendous desire for pictures of pregnant women of size because I think so many fat women have that "Oh-My-God-What-Am-I-Going-To-LOOK-Like" anxiety. 

The Shamu obsession, I call it.

The Not-Looking-Pregnant-Surprise

The ironic gotcha to all that worry is that once I was well into pregnancy, I was disappointed to realize that I didn't look pregnant at all. 

People kept looking at me and wondering where the pregnancy belly was, I could see it in their eyes.  Well, it was there ─ it just wasn't visible to the casual onlooker.  I have a big ole rack-o-doom and that tends to hide any belly popping out pretty well, plus my baby was facing my belly (occiput posterior) for much of the pregnancy, which means you "show" a lot less (cause the baby's behind is facing the other way!). 

I was so NOT showing in pregnancy that most people couldn't even tell I was pregnant until the baby was nearly born.  My classic story of this was when I had to move during my 8th month of pregnancy.  I showed up to my new doctor's office, told them I was transferring care there from another state ─ and they eyed me and asked me if I needed a pregnancy test!  I said, uh no, I'm 8 months pregnant already and if you need confirmation, you can come over here and feel her kicking!  They still looked dubious but took my word for it. I was so upset that they couldn't tell I was pregnant even at that point.

The only time anyone knew I was pregnant was just before I gave birth at 40 weeks.  I was in an elevator, going up to my last OB appointment, and a doctor on the elevator remarked on my pregnancy (he didn't know me; he was just being kind and making small talk).  I could have kissed him!!  Finally, FINALLY, someone saw I was pregnant.

So in the beginning, I was most worried about just how large I might get in pregnancy, only to have the ironic problem of no one even knowing I was pregnant most of the time.  Some fat women do look obviously pregnant, but some don't.  A lot depends on factors like the position of the baby, your shape ("pears" show more than "apples" or "hourglasses"), and your overall frame. 

If you are bothered by folks not knowing you are pregnant, the secret is to wear obvious maternity clothing, stand with your hand massaging your belly a lot, and talk a lot about your pregnancy.  That will make it clear to all but the most oblivious by-stander that it's not just fat but actual baby in there too.  (Sad we have to be so OBVIOUS about it, but hey, if it brings you peace of mind, go for it.)

The Hard-Belly-Surprise

The biggest thing that surprised me about my actual pregnant belly was that it was hard. 

I was used to my belly being a bit more on the soft and squishy side ─ not flabby but not rock-hard either.  But in pregnancy, my "bump" was quite hard and that really surprised me.

The not-so-lovely part of this was that the squishy parts then drooped down to the underside of the baby bump and I developed an "overhang" that I'd never had before.  Eywww.

Now, I'm generally a lot more self-accepting than most but even I had trouble being loving and accepting of the big belly droop that sent all my fat south for the winter.  Permanently. 

That was a not-so-pleasant surprise.

And it only got worse with each kid. 

Four of 'em.

The Postpartum-Belly Reality

I have to be frank about this ─ this belly droop thing has been hard to deal with.  Honestly, it's not a part of my body that I'm so at peace with anymore. 

Hard as it may be for some people to believe, I really was okay with my belly before babies.  It wasn't flat, it did have a bit of a roll, but nothing all that remarkable. I carried more of my weight in my boobs, hips, and legs.  I was okay with my belly.  I wasn't photographing it and sending it off to magazines, but I really didn't hate it and I really did enjoy the fact that my waist was so much smaller than my hips, giving me that va-va-va-voom hourglass vibe. 

But post-children ─ oy.  The va-va-va-voom factor?  It va-va-va-vrooomed off to another universe.  The belly droops down now in a way it never did before.  If I move in just the "right" way, I can hear the "slap-slap-slap" sound of my flesh hitting against itself.  It never did that before children!  Oh my gosh, I cannot tell you how much I absolutely loathe that.

And that hourglass figure?  Well, it's not a straight line but it's closer.  I gained a lot of abdominal fat in my pregnancies, and I dislike that for a number of reasons, both aesthetic and more importantly, because abdominal visceral fat is much more of a health risk.  I used to be very much a pear, or at least an hour-glassy pear with boobs.  Now I gained an apple to add to the pear with boobs, leaving me just fat all over.  That didn't make me very happy. I don't mind being fat, but I really liked actually having a shape.  Now, I feel more like a blob.

The extra abdominal fat certainly wasn't from gaining "too much" weight.  I gained a total of 5 lbs. net (lost 10 or so and then regained 15) on average with each child.  I bounced around a bit between each but ended up at about the same weight I started my first pregnancy.  However, you'd never know it from looking at me.  I look quite a bit heavier now than I did before my pregnancies.  And that sucks, I have to say.

It sucks not because I'm fat but because I look a lot fatter than I really am.  I basically am the same weight as 16+ years ago....but I sure look a lot heavier.  I'm not thrilled with that ─ but the real reason it sucks is because I know from the research that abdominal fat really is more risky. Even though I didn't gain "too much" and even though my eating habits actually improved from pre-pregnancy....I look more at risk, and probably am more at risk.  Damn.

The Lipedema Effect

As a side note of interest, I should point out that the bellyfat gain is probably due to lipedema (warning: not a fat-acceptance link).

People with lipedema (not the same as lymphedema) have a tendency to gain abnormal fat deposits in the lower body, especially the legs, but sometimes also in the abdomen or upper arms. They often gain a lot of these fat reserves during times of major hormonal changes, like puberty, pregnancy, menopause, etc.

My legs look just like the picture here, my legs got bigger symmetrically, I have the classic "cankles" with the ring overlap at the bottom yet my feet are not affected, and it is extremely painful to have any pressure on my legs, especially my lower legs.

While the lipedema fat gain did happen a bit, it was not too bad with the first few pregnancies. However, in the fourth pregnancy (in my 40s), the combination of pregnancy plus perimenopause plus postpartum thyroiditis did seem to add an awful lot of fat, both around my ankles and in the abdominal area.

So while I'm technically at the same weight I started my pregnancies out with, my fat levels have definitely increased, and that's been difficult to be at peace with.

Now, the belly droop thing is pretty common among women of size after pregnancy.  Fat women often experience this, regardless of how much weight they gained, how they gave birth, etc.  (Some get it without pregnancy too, especially if they've had a lot of drastic weight loss/regain in their lives.) 

But mine may be worse because of my 2 cesareans, because many women (fat or skinny) who have had cesareans find they have a post-cesarean "shelf" or "flap."  I'm sure some would be there anyhow without cesareans, but most cesarean moms really do see a marked increase on the belly flap-o-meter, and I'm sure being fat and having lipedema and having had cesareans only magnified that lovely effect.  [Another *#ing gift from my cesareans!]

So all in all, I've had some real challenges to my body acceptance after four children.

Belly Ambivalence

I take some comfort in knowing I'm not alone in my belly ambivalence, though.  A lot of women have droopy bellies postpartum, a ton of stretch marks, and a different overall shape than before. 

A change that drastic ─ well, it's just not that easy to come to terms with, no matter how much you love your body in general, or how much you adore your babies and wouldn't trade them for the world. So having a hard time coming to peace with your body afterwards is very normal, as you can see here:

http://www.theshapeofamother.com/

Beware, though, this is not a body-acceptance or fat-acceptance site at all.  These women have all the self-hate of their bodies (and especially their fat bodies) that is so typical of women in our society.  Add in the wrinkly, saggy belly that is universal immediately postpartum, and the body hate talk there can be really strong at times.  So while the pictures at Shape of a Mother are great to see, you should know that the self-hate talk may be triggering for some. 

Personally, I still find the site useful, even though I find the self-loathing and pro-dieting talk frustrating. I try to remember that it does reflect the ambivalent feelings many women have about their bodies post-partum ─ magnifying whatever body image issues they already had pre-pregnancy ten-fold.  Plus I just don't know any other sites out there that have such honest pictures of postpartum bodies. So I value the absolute honestly of the pictures themselves enough to try and overlook the self-hate talk.

Here is the link to the category of pictures of pregnancy and post-pregnancy bellies in women of size:

http://theshapeofamother.com/category/plus-sized/

[Again, be warned that there's lots of diet talk and WLS (weight loss surgery) discussion there.]

Belly Honor

No, it's not easy to stay at peace with your body (and especially your belly) during pregnancy and post-partum.  There are many challenges to body image, and the natural changes that come with pregnancy can exacerbate the body image issues of even the most self-accepting woman.

Still, it's important to honor the vital work that our bodies did, to love every bump and curve for the job it did bringing a new soul to the earth, growing a healthy being and helping it into this world, and nurturing that new life afterwards.

I guess my main message on this is that it's normal and okay to be a bit ambivalent about your body shape and condition after birth (even long after birth).  Don't hate on it, recognize the important work it did ─ but realize that it's totally normal to have some ambivalence about it too.

Acknowledge that, and then take some time to honor your belly anyway. 

To honor my belly despite my ambivalence, here are some shots of me several years ago in my last pregnancy.  I was "overdue" and impatient to have the baby, but I'd been down the Seduction to Induction Road before, knew how often it leads to a cesarean, and refused to get lured into that trap again.  So I was waiting....and waiting....and waiting...and waiting.  Baby didn't come until nearly 43 weeks by LMP (nearly 42 by adjusted dates).  Augh!

So to distract myself and to have some fun in those last few days, I put on my oldest, ugliest painting clothes, gave my kids a bunch of washable tempera paint, went out into the back yard, stuck out my belly, and gave them a new and unique painting canvas. 

They were young; the resulting artwork is probably not beautiful to anyone in the world except me, but we had a BLAST.   

I remember that belly-painting session with tremendous fondness.  I hope they do too. 

So I honor my belly, stretched out and saggy and droopy as it was (and still is), for all the work it did bringing my wonderful babies to me, like this one, below. [Yes, she is the one in-utero above.]

It was totally worth it, every bit of it.  

Enjoy. And find a way to honor your bellies, too.

*Art Docent Hints: If you enjoy a good mystery and want to try and deciper the painting, look for the picture of the baby they drew.  Look for the green head with a brownish arm sticking out to the side underneath (the rest of the body is a bit amorphous, I'm afraid). Also look for the word "baby" on the side.  There was an arrow below it, pointing to the baby, but it got obliterated by an overenthusiastic toddler.  Then they filled in the blank spaces with random colors and swirls. The final result was a bit Picasso-ish, but hey. 

**Fetal Position Postscript: For the curious, yes, in this picture my baby bump is really quite visible, but then my baby in this pregnancy was in the most optimal position for birth, which is anterior.  That means the little butt was sticking out in front, making a nice big bump to paint on.  In my first pregnancy, when I didn't look pregnant at all, baby was posterior and in that position the baby butt doesn't stick out and make much of a discernible bump.  The difference? I saw a pregnancy-trained chiropractor and got some adjustments.  That made my last pregnancy SO much more comfortable, and it helped baby to be anterior after 3 prior pregnancies with a posterior baby!  Trust me, that's a MUCH easier labor!

About Time: Asking Fat Women About Their Experiences

This is one of those no-duh studies, but I thought it was interesting enough to pass along.  Here's the study abstract.  [emphasis mine]

Nyman VM et al.  Obese women's experiences of encounters with midwives and physicians during pregnancy and childbirth.  Midwifery. 2008 Dec 17. www.pubmed.gov/19100667

OBJECTIVE: To describe obese women's experiences of encounters with midwives and physicians during pregnancy and childbirth.

DESIGN: A qualitative study using a phenomenological approach. Data were collected by means of interviews that were tape-recorded.

SETTING: The women's homes or at a hospital in western Sweden.

PARTICIPANTS: 10 women with body mass index greater than 30, three primiparous and seven multiparous, who had given birth at a hospital in western Sweden in the period between October 2006 and September 2007 were interviewed four to six weeks after childbirth.

FINDINGS: The meaning of being both obese and pregnant is living with a constant awareness of the body, and its constant exposure to the close observation and scrutiny of others. It involves negative emotions and experiences of discomfort. Feelings of discomfort increase as a result of humiliating treatment, whilst affirmative encounters alleviate discomfort and provide a sense of well-being.

CONCLUSION AND IMPLICATIONS FOR PRACTICE: Obese pregnant women are a vulnerable group because obesity is highly visible. Caregivers tend to focus on providing care to obese patients somatically, but are additionally in need of knowledge about care from the woman's point of view.

Many obese women have negative experiences of health care that they have to overcome.

It is necessary to individualise care for obese pregnant women, which involves taking time to give the women an opportunity to tell their own story.

Caregivers have to promote health but it has to be done honestly and respectfully.

In order to avoid judgmental attitudes and causing increased suffering for obese pregnant women, midwives and physicians need to be conscious of, reflect upon and verbalise their own attitudes and power. 


My Comments

I wish more doctors and midwives would reflect thoughtfully upon their attitudes, assumptions, and biases around "obesity," and realize just how much negative impact insensitive and fat-phobic care during pregnancy and birth can have.

AND if they'd only realize that "promoting health" doesn't necessarily have to mean promoting weight loss ─ that health can be promoted without dieting/weight loss being the keystone.

How much could outcomes be improved if they promoted Health At Every Size instead of weight loss as the goal?Sigh.

*Your comments?

Score!! Winter Stuff in Extended Sizes

I've written before about the difficulties I've encountered finding good rain gear and winter coats in extended plus sizes.  It's a problem that frustrates me no end.  I'm a chronically cold person (even when my hypothyroidism is well-controlled), and I get cold far more easily than anyone around me.  I need good warm clothing, sweaters, raincoats, and winter coats. 

We discussed before that my best sources so far were Junonia (women's sizes to 4x, sometimes 5-6x), and sometimes Land's End (women's sizes to 3x, men's sizes to some 4-5x) and L.L. Bean (some women's sizes to 3x, men's sizes mostly to 2x but a few 3x).  I can sometimes get outstanding stuff in these companies, but not always. 

The quality at Junonia really varies; some stuff is great, and some stuff isn't, either in fit or in quality. I got a ski jacket from them that was a huge disappointment, and a fleece jacket that was only so-so. And while they have some of the QuickWik-type materials and some ski wear, the stuff I've gotten from them in these have not been of the quality my kids get at REI or other major sports labels.  There's really a noticeable difference in terms of high-tech gear that helps wick away moisture or helps hold in the heat etc.  And as I see my kids with the really good stuff, I think ─ why can't I have that stuff too?

Land's End and L.L. Bean usually have some good stuff, and I got a couple of really great moderate-cold coats from them last year.  I also got a great wool sweater (not scratchy at all) from L.L. Bean that I use for keeping warm inside.  But the problem is that LL Bean stuff typically only goes up to a 2x in men's. Both LL Bean and Land's End only go to 3x in women's (not quite big enough in the boobs for me).  So, not always the best match for me.

Well, now I have a new source: Columbia Sportswear.  I knew about this company before, but last time I checked they didn't have women's coats anywhere close to my size.  My husband bought me a men's extended size coat from them 12 years ago, but it wasn't that great.  So I never really considered shopping for myself there.

But recently, a friend of mine gave me a "friends and family" pass (major discounts!) to Columbia's online store. My oldest son needed a bigger ski jacket, so I was hoping to use the pass to get a really good ski jacket for him at a halfway decent price.

When I went online to shop, though, I discovered that Columbia now carries extended sizes.  Score!!!

As is so typical these days, they only carry women's sizes to a 3x, which is almost but not quite enough for me....BUT they had men's sizes to 4x and 5x at times.  Whoohooo!

While it ticks me off majorly that more accommodation is made for men of size than for women of size (i.e., men are "allowed" to be fatter than women, and "allowed" to have more functional and quality clothing in extended sizes), I had to take a deep breath and move on.  At least they had some stuff in 4x, and I hoped the men's 4x might fit me. (Men's plus sizes are shaped differently ─ bigger in the belly and smaller in the chest and hips than I am ─ so it wasn't a sure thing). 

Because I had this one-time pass for a major discount, I took a risk and ordered a whole BUNCH of things from Columbia.com in 4x, crossing my fingers that they would work.  

Well, I got my package this week and IT WORKED!!!  I am so stoked.  I got a moisture-wicking shirt for workouts, a couple of full-zip or half-zip light jackets/fleeces, a high-tech wicking half-zip for layering warmth, a rain jacket (with special lining for more warmth), a soft-shell jacket (fleece on the inside, waterproof on the outside), and a full-on ski parka. 

I tried them all on and they all worked.  And the quality was way better than the stuff I ordered via Junonia, Land's End, or L.L. Bean.  Whoohooo!

I almost bought a pair of hiking pants too, but I decided not to risk buying pants at this point.  Men and women's shapes are too different and I've not had good luck buying men's pants in the past, so I didn't want to waste money on something I couldn't try on in person. 

But to get such ultra-warm, high-quality coats in my size?  Freakin' awesome when you consider I've been looking for years for quality stuff like this. 

Oh, and my son?  Got an AMAZING ski jacket ($260 retail!) for $90, plus some fitness shirts, hiking shirts, rain pants, and ski pants.  All very high-quality materials and workmanship, and they will keep him well-equipped for skiing, snow caving, wilderness survival, fencing, and Boy Scout hikes. 

I'm way poor now but it was worth it!  All in all, an excellent find!  http://www.columbia.com/.  They don't go to 4-5x in everything, alas, and they are quite pricey without the discount pass ─ but they had quite a few choices in coats, at far better quality than most other sources. Worth the price if you are needing a really good winter coat.

Can Fat Prejudice Be Changed?

Weight bias among healthcare professionals is a significant problem ─ but how do you combat it? 

Here are a couple of recent studies that discuss that.  The first is a review of other studies, and the results are not very encouraging.  The second is a bit more encouraging. 

How do you think we can best combat the issue of weight bias/stigma among healthcare professionals?


Daníelsdóttir S, O'Brien KS, Ciao A. Anti-fat prejudice reduction: a review of published studies.  Obes Facts. 2010 Feb;3(1):47-58.   PMID: 20215795

Division of Psychiatry, Landspítali-University Hospital, Reykjavík, Iceland.

Abstract

Prejudice against those who are perceived as 'fat' or obese (anti-fat prejudice) is rife, increasing, and associated with negative outcomes for those targeted for such treatment.

The present review sought to identify and describe published research on interventions to reduce anti-fat prejudice. A systematic search of relevant databases (e.g. PsychInfo, PubMed, Scopus) found 16 published studies that had sought to reduce anti-fat prejudice.

Most notable was the lack of research on interventions for reducing anti-fat prejudice. Methodological problems that limit the interpretability of results were identified in the majority of studies found. Interventions employing more rigorous experimental designs provided at best mixed evidence for effectiveness.

Although several studies reported changes in beliefs and knowledge about the causes of obesity, reductions in anti-fat prejudice did not typically accompany these changes. Anti-fat prejudice interventions adopting social norm- and social consensus-based approaches appear encouraging but are scarce.

The lack of prejudice reduction following most interventions suggests that psychological mechanisms other than, or additional to, those being manipulated may underpin anti-fat prejudice. New directions for researching anti-fat prejudice are suggested.

Given the strength of antipathy displayed toward those who are perceived as 'fat' or obese, research in this area is urgently required.



O'Brien KS, Puhl RM, Latner JD, Mir AS, Hunter JA. Reducing Anti-Fat Prejudice in Preservice Health Students: A Randomized Trial. Obesity (Silver Spring). 2010 Nov;18(11):2138-44.  PMID: 20395952

School of Psychological Sciences, University of Manchester, Manchester, UK.

Abstract

Anti-fat sentiment is increasing, is prevalent in health professionals, and has health and social consequences. There is no evidence for effective obesity prejudice reduction techniques in health professionals. The present experiment sought to reduce implicit and explicit anti-fat prejudice in preservice health students.

Health promotion/public health bachelor degree program students (n = 159) were randomized to one of three tutorial conditions. One condition presented an obesity curriculum on the controllable reasons for obesity (i.e., diet/exercise). A prejudice reduction condition presented evidence on the uncontrollable reasons for obesity (i.e., genes/environment); whereas a neutral (control) curriculum focused on alcohol use in young people.

Measures of implicit and explicit anti-fat prejudice, beliefs about obese people, and dieting, were taken at baseline and postintervention. Repeated measures analyses showed decreases in two forms of implicit anti-fat prejudice (decreases of 27 and 12%) in the genes/environment condition relative to other conditions. The diet/exercise condition showed a 27% increase in one measure of implicit anti-fat prejudice. Reductions in explicit anti-fat prejudice were also seen in the genes/environment condition (P = 0.006).

No significant changes in beliefs about obese people or dieting control beliefs were found across conditions.

The present results show that anti-fat prejudice can be reduced or exacerbated depending on the causal information provided about obesity. The present results have implications for the training of health professionals, especially given their widespread negativity toward overweight and obesity.