Americans have been warned for years about the perils of being overweight or obese. Indeed the risks for a host of complications increase steadily as the pounds pile on. For many people, the risks can be temporarily ignored; after all, it takes years to develop heart disease or Type II diabetes. But for one segment of the population, the risks are immediate and grave: Pregnant women.
For obese women expecting a child, the nine months of gestation bring with them potentially life-threatening complications (to mother and child). Chief among the issues related to obesity in pregnancy are pre-eclampsia, gestational diabetes, and cesarean section. The New York Times published an article the other day outlining the risks and providing the real-life example of one woman and her ordeal with a 29 week preemie.
So what are we to do? Weight is such a sensitive issue for so many women, even those without excess pounds. Doctors are often hesitant to bring up the subject of a patient’s weight during an office visit, for fear of offending the patient or “pointing out the obvious.” And the short time allotted for an office visit, for general practitioners as well as OB-GYNs, means that little time is able to be devoted to counseling in nutrition, exercise, and weight loss or maintenance. Traditionally, midwifery care focuses more on nutrition and holistic pregnancy care, but midwife care is not available to all women, nor is it the end-all, be-all solution.
We need greater outreach to obese women of childbearing age, both before and during their pregnancies. In fact, we may need to start sooner than that. According to the CDC, almost 1/3 of American teenagers are overweight or obese. Outreach needs to start as early as middle school, and continue throughout high school. We also need community resources to reach across all income strata, in the form of outpatient clinics/support groups as well as education for Medicaid and WIC recipients. We need to work to take away the shame and stigma of weight issues, while still providing empowerment for all people to take charge of their weight, and ultimately, their overall health.
We need more people thinking about solutions beyond “wider, sturdier” examining tables (as the NY Times article mentions). What are your ideas and experiences?
I think a good first step is to stop spreading unfounded fear to pregnant women who are fat, and misconceptions about what makes people fat to begin with. Here are some very informative sites dealing with plus size pregnancy.
http://wellroundedmama.blogspot.com/
http://www.plus-size-pregnancy.org/
the answer is excellent nutrition straight out of the shoot – breastmilk.
With my second pregnancy, I conceived while still trying to lose weight. I was overweight, but by the time my water broke at 41 weeks 6 days, I was obese. My first pregnancy I had no issues, and was not overweight. During both pregnancies I felt that I had a healthy diet. My first I was vegetarian, and only gained 35lbs. My second I started heavier, was not vegetarian, but ate organic/natural foods albeit many processed ones in those categories. During my 2nd pregnancy, I began to show some signs that I could become pre-eclampsic. My midwife had me eat more protein and up my magnesium intake with B12. That seemed to take care of it. I didn’t realize that I was very low on protein even as a meat eater. What I didn’t do is cut carbs – bad carbs. My baby was macrosomic at birth – 11lbs. I do believe that my weight and eating habits contributed some to the outcome of my birth and my health during pregnancy. I know it contributed somewhat to the size of my baby as well (though big babies are normal for my family and my husband’s). I am know 100lbs. lighter than the day I gave birth the second time. I eat a Traditional Foods diet, and I am more fertile than I have ever been in my life. I am convinced if I were to be pregnant again, that it would be my healthiest pregnancy and birth yet. I suggest folks look at Real Food for Mother and Baby by Nina Planck. There is some really good suggestions there.
as an obese woman I found myself discriminated against and treated stereotypically. I know I am fat. I also know that I am actually healthy and reasonably fit. But I do not habitually eat junk food and I do not drink soft drink (soda).
Here’s some details:
first pregancy I weighed about 95 kg…before during and after. I experienced a lovely pregnancy, I was tired in first and third trimesters, but I was able to rest as needed, I looked after myself. The birth was a 5 hour, calm waterbirth (no interventions). My baby was 2.6 kg (small, perhaps, but healthy).
second pregnancy (2 1/2 years later) I weight 102 kg at star and 108 kg at end…but this time I was over the invisable BMI line…just. So I had to be assessed to retain my low risk status and remain under the midwife care program. The assessment involved an ultrasound to check that baby wasn’t massive and a discussion with a ‘professional’ about my weight gain. Bub was average size and my weight gain was minimal, so I retained low risk status….went on to have a intervention free 4 hour labour, 3.2 kg healthy baby.
From what I was led to understand fat means bad eater, lazy and unfit. I know thin people would are ‘healthy’ BMI, but are less fit than me, eat terribly and would be at much greater risk of complications…
I think there is more to it than just weight. And it is not as simple as “eat well and exercise”…and yes, this is an issue that needs to be tackled in childhood…
But is the problem bigger than the indivdual (pun intended)…
Limor, I don’t think the fear is entirely unfounded. I like Well-Rounded Mama’s site, and I do believe that people can be healthy at (nearly) any size/weight. But I don’t believe that the majority of overweight and obese folks are healthy at their weight. If they were, we would not see the complications of excess weight rising in lockstep with our expanding waistlines. I don’t think this means we all have to strive to be a size 4.
Is the problem bigger than the individual, as Charle asks? I think it is. Yes, we all bear the individual responsibility for the food we put into our bodies and the exercise we output, not to mention seeking medical care to prevent or treat illness. But…. The most affordable foods seem to be the least healthy, most overprocessed ones. In many places access to fresh fruits and vegetables is limited, the quality is inferior, and/or the costs prohibitive. Not everyone can afford to join a health club, and not every city or town or neighborhood is safe and hospitable for walking, jogging, biking, etc. And we all know what a nightmare the healthcare system can be in this country. So in addition to individual effort and responsibility, we also need a cultural change.
Limor, you are right, it isn’t just about weight. There are some folks who simply are bigger than others, and I agree too that there are thin folks much more out of shape than some who carry more weight. I was a in shape big girl. I never hesitated to take on a physical challenge. Part of mine is genetics. However, I know now that even when I thought I was eating healthy, I really wasn’t. There are a lot of discrepancies even in what nutritionist recommend as healthy eating.
I most definitely do not believe an overweight woman should be treated as if she is a high risk right out of the gate. That is wrong – flat wrong. It is bigger than the outside appearance. I do think Lori is right though in that it does take deep consideration. If I had known then what I know now, things would have been healthier for me. It is about cultural change.
To me, much of the NYTs’ article read as another way to scapegoat women for the high cesarean rate in the US. Women have such diverse experiences in pregnancy and birth, and I think practitioners should be encouraged NOT to generalize broad categories of women, but to provide individualized care, based on the human being, not solely on some number like weight or BMI.
Initially this article cites that a woman of 5’5, 180 lbs as being at higher risk of complications like birth defects, “failure to progress,” and fetal and maternal death. Then, the actual case they refer to is a woman of 5’0 at 261 lbs with severe pre-existing medical problems (albeit seemingly related to her weight), including a stroke during her 7th month. It’s a scary case they are throwing out there, and I’m just not sure how well grounded this whole article is in evidence based research.
Complications in pregnancy such as pregnancy-induced hypertension and gestational diabetes undoubtedly relate to higher rates of interventions, but some of these interventions (including cesarean) can be related to pre-existing size bias.
If practitioners really believe bigger women can’t have vaginal births, they wont be encouraged, or even allowed to try without kicking and screaming. Articles like this one add to the misunderstanding and misinformation surrounding this issue.
And let’s look at the “evidence” this piece puts forward: Highlighted in a table is the rate of C-section by BMI: Women with a BMI of 35-40 have a 33% rate of cesarean births. What does this information really mean when this percentage rate is nearly the SAME as the c-section rate for all women living in the US today???
I’m only speaking from limited experience as a doula (no mother I’ve worked with has been overweight, let alone morbidly obese, but I have still seen the cascade of interventions, and the pressure to have them, really mess with the birth process) and my own experience as a woman who was faced with some of this bias from her own practitioner: I was told two days before I went into labor naturally that “women with BMI’s higher than 26 tend not to dilate without help [from induction agents].” And I am so happy I didn’t listen to her, because in my case, she was absolutely wrong.
It’s really great to dialogue about these issues–the more information mamas have, the better.
This was a very disappointing article, full of distortions and worst-case scenarios, and implying such experiences as the woman with the stroke are extremely common in fat women.
Yes, women of size are at increased risk of some complications. But by using odds ratios, they distort the magnitude of that risk and make it sound like it’s the most risky thing ever to have a pregnancy as a woman of size. In fact, many women of size have healthy pregnancies and healthy births…..for example, I somehow managed to have four healthy pregnancies and babies at a much higher starting weight than the woman in the article (she was 195 lbs starting weight, 261 at delivery due to PE). Despite being much 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 fat.
But THAT part of the obesity story (the healthy pregnancies and normal outcomes for many of us) doesn’t serve the agenda of the article (see below). To me it was not a well-balanced article at all. It didn’t discuss the possible risks in a reasoned and calm matter, nor did it acknolwedge the many women of size who have healthy pregnancies and babies, but instead created a hyperinflated sense of risk.
Furthermore, I dislike the mother-blaming in the article….the high cesarean rate today is due to all those obese mothers!!!! Actually the high cesarean rate in fat women is largely due to iatrogenic interventions, not an inability to give birth vaginally. If you look at the cesarean rate of fat women many years ago, they had rates very similar to women of average size. Nowadays their rate is MUCH higher, often because the rate of induction in women of size is SOOO incredibly high. If fat really prevented giving birth vaginally, it would have done so then too. But what has changed is the PERCEPTION of risk around women of size, and the management of their pregnancies and labors. Being perceived as high-risk and treated as high-risk creates a self-fulfilling prophecy in the delivery room.
Look at the attitude of the doctor in the article….doctors are defensive about c/s rates, he says, but cesarean surgery has to be weighed against the risk of vaginal birth in obese women. As if vaginal birth in obese women is riskier than a cesarean! Yet many doctors seem to feel so today. They have a totally distorted sense of risk around obese women, even those without complications.
Also, read the article again and look underneath for the deeper message. Look how it emphasizes the BURDEN on the local hospitals, and the EXPENSE of getting size-friendly equipment, the extreme RISKS faced by obese women….but they could fix that by centralizing care for this group!
See it for what it is, a marketing ploy for the concept of bariatric obstetrics. The new “trend” is to centralize care for obese women in one major hospital, and all fat women are then REQUIRED to go there. Think they’ll have access to waterbirth or natural birth or mobility in labor there? No, they’ll be pressured to diet/gain no weight in pregnancy, undergo extreme levels of testing, have their labor induced early (if they’re allowed to labor at all), get an epidural early “just in case,” and get sectioned at a very high rate. Because they’re fat no authority will question whether bariatric obstetrics results in better outcomes, and then these women will be strong-armed into major diets afterwards (and probably a lot of weightloss surgery). Yet long-term research shows that nearly all the diets will fail, many of the women with weightloss surgery will experience malabsorption complications, and that weight loss attempts are one of the major factors in weight GAIN over the long run. What they are doing will likely just worsen the problem, not improve it.
These bariatric obstetrics practices are the new cash cows for doctors and hospitals, as weight loss surgery centers have been in the past decade. They are potentially immensely profitable. But first they have to create their market by increasing the perception of extreme risk around obesity in pregnancy, so as to convince the insurance companies it’s necessary to pay for all this extra care, and make the fat women and their families (and their regular doctors) feel like they “need” it.
More and more I am hearing from fat women all over the country who are being DENIED even the opportunity for homebirth or for a VBAC trial of labor, simply because of weight, *regardless* of actual health or complications.. I am hearing from women of size in other countries who are being REQUIRED to go to these bariatric obstetrics hospitals. 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 style of care is forfeit. Right to bodily autonomy and integrity are everyone’s rights, regardless of fatness. But by exaggerating the risks of obesity and concentrating on the worst-case scenario stories, the authorities make a case for taking away just that.
The fuss over the “high risk” status of obese mothers is a red herring. What they are trying to do is ghettoize fat women for profit. I’m sure they think they are doing these women a FAVOR, but what they don’t see is the better outcomes for many that can come from LESS interventive care.
It is good to have resources when fat women DO experience complications like the lady in this article (just as it is for women of any size), but it is WRONG to imply that all fat women are at the same level of risk as this, and that we all require “special” care. These bariatric obstetrics centers are a disaster in the making, and this article was a marketing ploy, pure and simple.
I will be blogging about this article and about the denial of VBACs to women of size on my blog. I invite readers to come and see what I have to say.
I want to add that assuming a person is unhealthy because they’re fat, or assuming a person is healthy because they’re thin is totally ridiculous. It’s also impossible to extrapolate, based only on a person’s weight, whether they follow a well balanced healthy diet, or a poor one. Just because someone is fat doesn’t mean that they eat nothing but Doritos and lard, and just because someone is thin doesn’t mean they eat nothing but tofu and kale.
Unfortunately there’s another assumption about weight and diet that is even more damaging than the above, that body size can be controlled by external factors. It’s been proven time and time again that genetics controls a person’s size. A person might be able to change their weight slightly with diet and exercise, but often those changes don’t translate to going from a BMI value in the obese category to one in the “normal” weight category.
Obviously good eating habits are very important in pregnancy, and I have no problem with doctors addressing that issue with their patients. However, they need to address it with all patients equally, instead of assuming that fat pregnant women are eating junk and thin pregnant women are eating healthily.
This is anecdotal, but I’ll throw it in anyway. I am by far the fattest person in my group of friends. Most of them would be considered normal weight, with one or two in the overweight category. According to my BMI (which is a total BS measure of anything) I am morbidly obese. I also have the best eating habits of this group. Unlike them I rarely eat fast foods or even processed foods. I cook almost every night from scratch and incorporate loads of fruits, veggies, and fiber in my diet. I also rarely eat red meat, opting for chicken and beans instead. This difference in eating habits applies to our pregnancies as well. They are not thinner than me because of their eating habits, nor are they thinner because of their exercise routines. They’re thinner because of genetics.
Marginalizing and stigmatizing fat women when they’re pregnant, above and beyond the usual treatment that they get from healthcare providers, will only cause them to avoid seeking medical care. A problem that already exists for fat people. How will that lead to better outcomes for anyone?