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Maternal Obesity from All Sides

June 15th, 2011 by avatar

[Editor’s note:  In this, our last segment of the Maternal Obesity from All Sides series, Pamela Vireday shares with us some thoughts regarding prevention, and lived experiences of women of size.  To read the series from the beginning, go here Thank you to ALL of our contributors to this important series. Haven’t shared this conversation with your social media circle yet?  Take a moment to Tweet it or share it on Facebook!]


Rethinking Prevention and Treatment

Maternity care providers usually consider only 3 ways to improve patient outcomes: weight loss before or between pregnancies, restricting gestational weight gain, or incorporating high-intervention care models.  Let’s look at these approaches first, and then examine some alternatives as well.

Weight Loss Before/Between Pregnancies

The Holy Grail of Prevention in most researchers’ minds is weight loss before or between pregnancies.  But is this wise?

Research strongly supports the idea that significant weight gain before pregnancy increases the risk for complications, leading doctors to focus on the idea of weight loss preventing them. In fact, some research does support weight loss as prevention.  However, this weight loss can come at a price.

Many women of size who lose weight between pregnancies report gaining significantly more in the subsequent pregnancy; 41%  compared to 18% in one study.  Chronic dieters  also tend to have more excessive weight gains in their pregnancies. Furthermore, a history of weight loss or frequent weight cycling is a strong predictor of subsequent large gain outside of pregnancy, and long-term weight loss maintenance is rare.

This is not to say that the weight loss option cannot be discussed with women; some may be desirous of this approach. However, women also have the right to decline it.  An alternative approach may be to choose a “Health at Every Size” program ─ emphasizing healthy habits independent of weight loss status.

Therefore, the potential benefits of weight loss now have to be weighed against its potential to cause more weight gain and complications in the long run.

Prenatal Weight Gain Restriction

More and more, researchers have been focusing on restricting prenatal weight gain in high-BMI women in order to improve outcomes. However, recommendations for optimal prenatal weight gain in this group are hampered by study design issues, lack of uniform definitions of obesity and weight gain categories, and contradictory findings.

Research does suggest that high weight gains are associated with increased rates of cesareans, macrosomia and pre-eclampsia.  However, causal interpretations for this are questionable. Iatrogenic factors influence the cesarean rate because of the fear of macrosomia and lack of blinding about weight gain. And higher weight gain is most likely a side-effect of pre-eclampsia, not a cause of it. Only macrosomia seems closely tied to high weight gain.

Even so, many care providers are now pushing ultra-low gain policies for their obese patients. However, this is not without risk.  Research shows that there are increased rates of adverse outcomes with this approach, including small-for-gestational–age (SGA) infants, prematurity, and perhaps infant mortality.

At this time, the Institute of Medicine recommends a weight gain of 11-20 lbs. for all obese women.  Emerging research suggests that optimal weight gain may differ by class of obesity, but doctors must balance the risks of SGA and prematurity against the risks of macrosomia and cesareans carefully, especially for mid-sized obese women (BMI 30-40).   Placing a pregnant woman into a fat and protein-burning state for maintenance of energy levels may not be the best thing—for mother and fetus, alike.

Furthermore, studies that examine lifestyle interventions in obese pregnant women show mixed results.  Some show reduced gain, while others showed little difference or even increased gain instead.  Many show little difference in birth weight, complications, mode of delivery, or neonatal outcome.  If reduced gain makes little difference in outcomes, why risk it?

Remember, good nutrition should always be the priority over rigid weight gain goals; altering prenatal weight gain through scorched-earth interventions may cause more harm than benefit. And researchers must be careful that focusing on weight gain goals does not encourage punitive practices or overly restrictive advice among clinicians.

Ghettoizing Women of Size

Increasingly, research calls for high-BMI women to be managed as “high-risk” patients.  In practice, this means that obese women are often not considered eligible for low-intervention care models and “alternative” birth choices. Some care providers are even declining to see high-BMI patients at all.

Obese women increasingly report being “ghettoized” into “bariatric obstetrics” practices, unable to access local OBs, midwives, or community hospitals. Many report not being allowed to have a homebirth, birth center birth, waterbirth, or even a VBAC. Many are strongly pressured into a high rate of interventions with few alternatives.

Some providers assume that outcomes will be better with high-intervention protocols across the board, but this has not been proven. While sometimes interventions are needed, anecdotally many women of size find that high-tech care models result in poorer outcomes, more traumatizing births, and more interference with breastfeeding.

Research shows that outcomes are good for other women with midwifery care, even women with “moderate” risk factors.  And since many obese women do have normal pregnancies and births, obese women without serious complications should still be able to choose midwifery care, community hospitals, “alternative” care, and low-tech models of care. To paraphrase Susan Hodges of Citizens For Midwifery, how much perceived ‘risk’ does it take to supercede a mother’s right to patient autonomy?

Other Alternatives for Minimizing Complications

When researchers fixate on weight loss, weight gain restriction, and high-intervention care models as the only methods of preventing problems, they lose the opportunity to explore other sensible avenues of prevention.

The most basic way to improve outcome is to emphasize the importance of a pre-conception check-up to check blood pressure, blood sugar, thyroid function, and prenatal vitamin/folic acid intake. These are vital because the most serious complications in obese women usually come from those with uncontrolled pre-existing conditions.  The importance of good nutrition and exercise for preventing complications should be discussed, but without lecturing and moralizing.

The importance of exercise is perhaps the most potent message for women of size to hear for minimizing complication rates. In one study, the risk for GD in obese women was cut nearly in half by regular exercise. Some studies suggest it may lower the risk for pre-eclampsia as well.  Studies in non-pregnant people show that exercise can improve health greatly, independent of weight loss.

Restrictive dietary advice is controversial.  Many care providers advise obese clients to limit high glycemic-index carbohydrates, but research on this approach is contradictory .  A Cochrane review found some benefits but overall inconclusive results. Since many women of size are insulin-resistant, it seems sensible to encourage complex carbs combined with protein, since this significantly improves glucose and insulin response.  That being said, caution should be taken in implementing a low glycemic index diet; severe carbohydrate restriction can result in a ketogenic state—putting both mother and baby at increased risk.

It has long been speculated that a higher dose of folic acid might lower the risk for birth defects in obese women, and some organizations recommend doing this.  Other resources recommend measuring red blood cell count folate concentration instead and giving additional supplementation only for those with low concentrations.

Some experts have also speculated that supplementation with higher doses of vitamin D before or during pregnancy might help prevent some cases of gestational diabetes, hypertension disorders, and cesareans.  However, research so far has been mixed.

Another preventive option that has been proposed by some organizations is daily low-dose aspirin after the first 12 weeks for those obese women most at risk for pre-eclampsia. Like folic acid and vitamin D, this too needs to be studied further for efficacy and safety but is an intriguing possibility. Because aspirin intake during pregnancy can result in deleterious outcomes in some mother/baby dyads, antenatal aspirin use should only be maintained under the careful guidance of the woman’s maternity care provider.

Care must be taken not to use a too-small BP cuff, which artificially inflates blood pressure readings and can result in over diagnosis of hypertensive disorders. Large arms over 34 cm need a large cuff, and some need a thigh cuff. Care must be taken with forearm readings, as these tend to overestimate blood pressure too.

Anecdotally, many women of size (like all women)  find that avoiding inductions is an important part of improving their outcomes. Indeed, one study of obese women found a c-section rate of 19% with spontaneous labor (vs. 41% for induced labor), and that induction was the start of many complications in this group.   Because induction rates can be as high as 50% in very obese women; avoiding induction may help lower cesarean and complication rates. Adjusting due dates for menstrual cycle length may also help reduce the number of inductions for postdates pregnancies in high-BMI women.

A tincture of patience in labor may be helpful too. Many cesareans occur because of a “failure to wait” among care providers.  Since their first stage of labor tends to be slower and because many care providers opt for cesareans more quickly in obese women, it’s important to allow a truly adequate labor before opting for surgery.

Many high-BMI women report having cesareans for fetal malpositions, and some research supports this.  This suggests that interventions such as manual rotation skills or prophylactic chiropractic care might help lower their rate of cesareans.  Anecdotally, many women of size report that chiropractic care was very helpful in pregnancy and labor.

The fear of big babies is another factor that leads to many inductions and cesareans. Avoiding fetal weight estimations may help avoid harmful interventions and a lower threshold for surgery.

Re-examination of surgical care regimens may also improve outcomes in those who do have cesareans.  For example, many clinicians were taught to use vertical incisions and subcutaneous drains in cesareans in very obese women, yet recent research finds these actually increase the risk of wound complications strongly.  Additionally, a higher dose of antibiotics may be needed in morbidly obese women, and those who develop infections may benefit from extended treatment with more frequent dosing regimens.

However, the most powerful measure for prevention in the pregnancies of women of size is simply having a care provider that does not see them as a ticking time bomb, who understands that large bodies can work “right” too, and who truly believes in their potential to give birth vaginally as well.  Remember the power of the self-fulfilling prophecy; be proactive about complications but expect normalcy.

Conclusion

Weight loss before pregnancy is something that can be considered on an individual basis for those who wish it, but we cannot place all our prevention eggs in one basket.

High-BMI women should probably avoid very high weight gains, but extreme interventions to restrict weight may increase the risk for some adverse outcomes as well and must be viewed with caution.

Forcing all obese women into a high-risk, high-intervention care model penalizes those without complications and may cause more harm than good. Women of size, like all women, deserve the right to patient autonomy and access to care that will improve their outcomes.

Clearly, the pregnancies of high-BMI women carry a higher risk for some complications.  It is important to care about lessening this risk and promoting proactive care. However, we must not let hyperbole about this risk rush us into unwise, ineffective, and even dangerous interventions. We must start examining other options for prevention as well.

Additional References and Links:

Subject Studies and Links
Weight Gain Before or Between Pregnancies and Complications Gethun 2007 http://www.ncbi.nlm.nih.gov/pubmed/17547882 LGA babies 

Villamor 2008 http://www.ncbi.nlm.nih.gov/pubmed/18375499 birth defects

Whiteman 2011 http://www.ncbi.nlm.nih.gov/pubmed/20640971 pre-term births

Paramsothy 2009 http://www.ncbi.nlm.nih.gov/pubmed/19305325 cesareans

Weight Loss and Prevention of  

Pregnancy Complications

Whiteman 2011 http://www.ncbi.nlm.nih.gov/pubmed/21544736 GD 

Glazer 2004 http://www.ncbi.nlm.nih.gov/pubmed/15475723 GD

Getahun 2007 http://www.ncbi.nlm.nih.gov/pubmed/17547882 LGA babies

Paramsothy 2009 http://www.ncbi.nlm.nih.gov/pubmed/19305325 cesareans

Prenatal Weight Gain Restriction in Obese Women Crane 2009 http://www.ncbi.nlm.nih.gov/pubmed/19208280 

Thornton 2009 http://www.ncbi.nlm.nih.gov/pubmed/19585925

Nohr 2008 http://www.ncbi.nlm.nih.gov/pubmed/18541565

Heude 2011 http://www.ncbi.nlm.nih.gov/pubmed/21258962

Riskin-Mashiah 2011 http://www.ncbi.nlm.nih.gov/pubmed/20642383

Low Gestational Weight Gain/Loss and  

Adverse Outcomes in Obese Women

Edwards 1996 http://www.ncbi.nlm.nih.gov/pubmed/8598961 SGA 

Chen 2009 http://www.ncbi.nlm.nih.gov/pubmed/18813025 infant death

Naeye 1979 http://www.ncbi.nlm.nih.gov/pubmed/474659 perinatal mortality

Dietz 2006 http://www.ncbi.nlm.nih.gov/pubmed/16477257 prematurity

Efficacy of Lifestyle Interventions in Obese Pregnant Women Guelinckx 2008  http://www.ncbi.nlm.nih.gov/pubmed/18221480 review of 7 trials 

Mottola 2010 http://www.ncbi.nlm.nih.gov/pubmed/20083959 less gain, no diff birth wt

Shirazian 2010 http://www.ncbi.nlm.nih.gov/pubmed/20013602 less gain, no less complctns

Wolff 2008 http://www.ncbi.nlm.nih.gov/pubmed/18227847 less gain, better glucose mtblsm

Polley 2002 http://www.ncbi.nlm.nih.gov/pubmed/12439652 more gain in ovwt group

Claesson 2008 http://www.ncbi.nlm.nih.gov/pubmed/17970795 less gain, no diff birth wt or CS

Guelinckx 2010 http://www.ajcn.org/content/91/2/373.long RCT, no diff in gain or outcomes

Quinlivan 2011 http://www.ncbi.nlm.nih.gov/pubmed/21466516 less GD, no diff in birth wt

Unequal Access to Lower-Intervention  

Care for Obese Women

Some Ob-Gyns in South Florida Turn Away Overweight Women” 

Midwife Group Won’t Accept Patient with BMI Over 40?”

Fat Mothers To Be Banned From Hospital

In Celebration of the Baby Bump

I Feel Victimized Because I’m Fat

Pregnancy and Doctor Doom – He Was Wrong, Wrong, Wrong!”

Too Fat For a Midwife/Birth Center

Too Fat to VBAC

So Why The BMI Restrictions in Waterbirth?”

Too Fat for a Homebirth VBAC

Too Fat for Vaginal Birth

Big Girth? Then You Can’t Give Birth

Woman Deemed ‘Too Fat’ for Pregnancy

Can They Refuse Me a Waterbirth?”

Experiences of Women of Size in Pregnancy Furber and McGowan 2010 http://www.ncbi.nlm.nih.gov/pubmed/20483513 

Nyman 2008 www.pubmed.gov/19100667

Exercise for Prevention of Pregnancy Complications Dempsey 2004 http://www.ncbi.nlm.nih.gov/pubmed/15533588 

Rudra 2005 http://www.ncbi.nlm.nih.gov/pubmed/16286850

Vitamin D Levels and Complications Ringrose 2011 http://www.ncbi.nlm.nih.gov/pubmed/21631991 hypertension and preg 

Zhang 2008 http://www.ncbi.nlm.nih.gov/pubmed/19015731 GD

Merewood 2009  http://www.ncbi.nlm.nih.gov/pubmed/19106272 CS

Barrett and McElduff 2010 http://www.ncbi.nlm.nih.gov/pubmed/20832734 general review

Lapillonne 2010 http://www.ncbi.nlm.nih.gov/pubmed/19692182 general review

Nutrient Deficiencies and Obesity Schweiger 2010  http://www.ncbi.nlm.nih.gov/pubmed/19876694 

Carlin 2006 http://www.ncbi.nlm.nih.gov/pubmed/16925330

Folic Acid Recommendations and Obesity CMACE/RCOG Joint Guidelines http://www.rcog.org.uk/files/rcog-corp/CMACERCOGJointGuidelineManagementWomenObesityPregnancya.pdf
Blood Pressure Cuff Size Maxwell 1982 http://www.ncbi.nlm.nih.gov/pubmed/6123760 

Graves 2001 http://www.ncbi.nlm.nih.gov/pubmed/11248756

Pierin 2004 http://www.ncbi.nlm.nih.gov/pubmed/15199302

Improving Cesarean Outcomes in  

Obese Women

Ramsey 2005 http://www.ncbi.nlm.nih.gov/pubmed/15863532 

Chelmow 2004 http://www.ncbi.nlm.nih.gov/pubmed/15121573

Bearden and Rodvold 2000 http://www.ncbi.nlm.nih.gov/pubmed/10843460

http://wellroundedmama.blogspot.com/2010/08/antibiotic-underdosing-in-obesity.html

Long-Term Efficacy of  

Weight Loss Programs

Aphramor 2010 http://www.nutritionj.com/content/9/1/30 

Bacon and Aphramor 2011 http://www.nutritionj.com/content/10/1/9

Martin 2008 http://www.ncbi.nlm.nih.gov/pubmed/18787526

Hill 2005 http://www.ncbi.nlm.nih.gov/pubmed/15867898

Jain 2005 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1309653/?tool=pubmed

Sarlio-Lähteenkorva 2000 http://www.ncbi.nlm.nih.gov/pubmed/10702760

Ikeda 2005 http://www.ncbi.nlm.nih.gov/pubmed/16029691

Garner and Wooley 1991 http://psycnet.apa.org/?fa=main.doiLanding&uid=1992-13614-001

Miller 1999 http://www.ncbi.nlm.nih.gov/pubmed/10449014

Wt Loss/Wt Cycling as Risk Factor for Subsequent Weight Gain/High BMI Jeffery 2002 http://www.ncbi.nlm.nih.gov/pubmed/12080451 

Korkeila 1999 http://www.ncbi.nlm.nih.gov/pubmed/10584040

Field 2004 http://www.ncbi.nlm.nih.gov/pubmed/14981219

Exercise for Prevention Sanz 2010 http://www.ncbi.nlm.nih.gov/pubmed/20675173 

Lee 2005 http://jap.physiology.org/content/99/3/1220.abstract

Church 2004 http://care.diabetesjournals.org/content/27/1/83.abstract

Hamer and O’Donovan 2010 http://www.ncbi.nlm.nih.gov/pubmed/19770655

Health At Every Size Bacon 2005 http://www.ncbi.nlm.nih.gov/pubmed/15942543 

http://wellroundedmama.blogspot.com/2008/07/health-at-every-size-paradigm.html

Ernsberger and Koletsky 1999 http://onlinelibrary.wiley.com/doi/10.1111/0022-4537.00114/abstract

 

 

 

 

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  1. June 15th, 2011 at 17:32 | #1

    Oh dear. I must take issue with the utilization of the word “ghettoize”. It has been used several times in this series and I have to ask that we take pause. Allowing this term into a birth vernacular needs to be done so with appropriate cultural, and de-stigmatizing context—if AT ALL!! We cannot rely on stigmatizing, possibly hurtful language rooted in so much historical oppression of so many people to express our privileged, albeit legitimate, experiences of marginalization. I encourage all of us to rethink the term, reject its use, and determine to set precedent of non-collusive speech.

  2. avatar
    Janie
    June 15th, 2011 at 17:38 | #2

    excellent once again. previous commenter, I do understand your hesistation with the term but I don’t think of it a racial term and I would imagine a writer would be hard pressed to find an alternative term that captures the essence the same way.

  3. June 15th, 2011 at 17:48 | #3

    Consideration of the words we use is essential. Thesaurus is always available.

  4. avatar
    Lisa Baca
    June 16th, 2011 at 16:34 | #4

    I am not a health professional. I was not obese at the time of my pregnancies (way back when). In planning to get pregnant, I asked for a check up and in explaining why baffled my doctor. They thought I should contact them if something went wrong, not try to anticipate undiagnosed conditions, so as to take them into account with my pregnancy. This was in 1974. I felt your post, even with the word ghetto in it, which I do not object to, was right on. I have a daughter with pre-existing oonditions and even if she never has children, I will always seek to help her find more natural ways to control any problems. If children come into the picture it becomes more important.

  5. June 16th, 2011 at 16:45 | #5

    I was impressed with the thoroughness of this article.

    I also think the term ghettoized is a bad term. First, it isn’t actually a word. Second, it brings images of the Ghettos of Nazi Germany and apartheid South Africa, which are injustices far greater than asking a morbidly obese woman to seek a particular site of care.

    One of things I have found is that the inability to monitor the fetuses of morbidly obese women in labor tends to get people very nervous. It a difficult problem if one is proceeding with an induction, which are not uncommon because of the high rates of gestational diabetes, gestational hypertension, and pre-eclampsia.

  6. June 16th, 2011 at 16:46 | #6

    I appreciate the mention of the need for higher doses of IV antbiotics. Very current. We were just talking about that article on the Academic OB/GYN podcast.

  7. June 16th, 2011 at 23:55 | #7

    Thank you for your understanding of the term ghettoized. @Nicholas Fogelson, MD

  8. avatar
    Futuralon
    June 17th, 2011 at 02:03 | #8

    I told the nurse at planned parenthood I wanted a preconception checkup and she had no idea what I might mean. She suggested I know what sort of tests I might want and get them a-la-carte. I would be interested in a post of what to ask for at such a visit.
    I also wanted to say this post is informative and useful to me as a fat chick planning a pregnancy.

  9. June 17th, 2011 at 07:20 | #9

    @ Futuralon: Good for you for seeking out preconeption care. We actually have a post coming up, in the next couple of weeks, that will answer your question. Dr. Michael Lu, Associate Professor, Obstetrics and Gynecology at UCLA, and Associate Director, Child and Family Health Training Program, sat down for an interview with our own Walker Karraa, and discussed his recommendations for preconception care. You won’t be disappointed!

    In the mean time, you might enjoy checking out, Before You Conceive: The Complete Prepregnancy Guide (Sussman, J., Levitt, B.) or Dr. Lu’s own book, Get Ready to Get Pregnant
    (both available on Amazon).

  10. June 17th, 2011 at 20:07 | #10

    In the recently published Los Angeles Maternal Birth Survey (LAMB), of the 151,813 live births in Los Angeles County for 2007, 38.3% of women were overweight/obese, 36.7% were uninsured; and 53.4% were unwanted pregnancy by mother, 41.0% were below poverty line <$20,000. 70.7% had no preconception counseling.

    Disparity of care is glaring.

  11. June 19th, 2011 at 15:05 | #11

    Like many of us, my mother smoked and drank socially when pregnant with her children. It was the “Mad Men” era and science and society had not met across the great tobacco divide to “ghettoize” recreational smoking and a cocktail now and then. Her mother, my grandmother, did the same.

    I am curious about how we would regard a mother who smoked or drank alcohol in her pregnancy. Her choice, she is comfortable with it, knows the risks, and feels the research is biased toward disease models as scare tactics, not generalizeable to all–particularly to her. (Generalizability is the hallmark of empiracly based quantitative studies)

    She feels demonized by care providers, and marginalized by society’s standards for “healthy” pregnant women. The non-stop no smoking advertisements offend and feel injurious.

    Would this be analagous? Would there be anything to learn in considering similarities or differences in the scenarios?

  12. avatar
    Janie
    June 22nd, 2011 at 16:06 | #12

    So are you saying that those of us who seek to have good healthy pregnancies while being fat are simply like your mother?.. we just don’t know any better? If that is what you are saying then you believe in one model for obesity. Food in, less activity.. obesity.. glossing over the numerous reasons for a person’s size.

    You get out that thesaurus out and come up with a word that describes isolating people into specialized groups based on their physical characteristics. You take offense at the word but don’t offer an alternative that fits the emotions that the word conjurs. An acceptable word when you have been the one made to feel that way.
    African American people have a higher incidence of high blood pressure. Are they asked to go to a “special” doctor for routine care that does not involved blood pressure?
    Perhaps the answer needs to be better training for health care professionals. Training that would allow them to treat ALL patients with the dignitiy and level of expertise they deserve.

  13. June 27th, 2011 at 20:34 | #13

    Thank you for your comments. Yes, I debated a long time over the word choice of “ghettoize” because I didn’t want to compare the seriousness of the situations, exactly as you say, and we do have to be careful about these things, coming from a place of comparative privilege. So I very much understand your concerns on that and thought long and hard about the very same thing.

    However, in the end, I could not find another word that worked as well. Yes, I checked a dictionary and thesaurus; Merriam-Webster’s online dictionary does have “ghettoize” listed as an entry, but their thesaurus did not have any equivalent words for it. One of their definitions of ghetto was “a situation resembling a ghetto, especially in conferring inferior status or limiting opportunity.” Sounds pretty apt to me.

    “Marginalize” was as close as I could come for a substitute, but I don’t feel it comes anywhere near the impact that these new policies are having. It’s not just simply about asking a morbidly obese woman to go to a different site of care, it’s about forcing these women into a model of care that is resulting in nearly 50% c-section rates (Weiss 2004)….even higher as BMI goes up. One study shows a more than 70% c/s rate for women with a BMI over 52 (Brost 1997).

    If nearly half to three-fourths of “morbidly” or “super” obese women are being cut, that’s a pretty serious situation, given the risks of surgery in people that size. But it doesn’t have to be that way; a recent study in the UK found that 70% of super obese women (Homer 2011) were able to give birth vaginally, if given a real chance to. It’s not that very fat women cannot give birth vaginally, it’s that common care protocols and exaggerated fears create a lower surgical threshold (Abenhaim and Benjamin 2011), and ultimately this is causing more harm than benefit.

    And many women of size are being categorically denied access to the model of care that many of us find gives us better outcomes, denying our right to patient autonomy. Many are being forced into inductions and cesareans with little choice (see the story recently posted on my blog). So YES, I chose the word “ghettoize” on that basis. You can of course continue to disagree, but I don’t feel the word is too strong at all, given some of the experiences women of size have been through and are facing daily now.

  1. June 24th, 2011 at 06:54 | #1
  2. January 12th, 2013 at 08:57 | #2