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Welcoming All Families Series: Welcoming Women of Size & Promoting Optimal Birth Outcomes

November 8th, 2012 by avatar

Continuing along in our occasional series on “Welcoming All Families” to our childbirth classes, this two part guest post is written by Pam Vireday,  creator of the Well-Rounded Mama blog.  Today, Pam shares how to promote optimum outcomes at the births of plus sized mothers. Click here to read the first post in the series, where Pam shared how to create childbirth education classes with women of size in mind. – Sharon Muza, S&S Community Manager

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In part one of the series,  we discussed how birth professionals can make women of size feel more welcome by creating a size-friendly space, by addressing special needs, by finding size-positive images and birth stories, and by addressing potential risks in a proactive, non-judgmental way.  Today, in part two, let’s discuss ways to promote optimal outcome in women of size.

Nutrition and Exercise

photo courtesy of Pamela Vireday

Many women of size find they feel better and have more stable blood sugar when they combine carbohydrates with protein instead of consuming carbohydrates by themselves. Modestly limiting carbohydrates at meals, eating smaller and more frequent meals, and using whole grains instead of refined carbs may also help promote euglycemia.

An even more powerful tool for optimizing blood sugar is exercise. Intensity of exercise is far less important than regularity of exercise, with daily exercise being optimal. Many women of size find walking, swimming, prenatal yoga, and water aerobics particularly friendly to larger bodies.

Nutrition Diaries

One of the most trying things for some fat women is the pregnancy nutrition diary. If used, these must be done with care.

After years of having every bite nit-picked, pregnancy food diaries can be very triggering for women with long histories of dieting or eating disorders. In addition, many providers don’t believe women of size no matter what they say. As one mom shared, “[My midwife] refused to believe what I recorded. She flat-out accused me of lying, telling me that I ‘must be living on ice cream and donuts.’”  This can be very disillusioning.

If you decide to use food diaries, question your assumptions about what fat women “must” be eating.  Some people eat normally and are still fat, while some thin women have terrible habits and yet are thin. Leave out assumptions, scolding, and lecturing, and find a way to neutrally help women analyze their own intake and gently adjust if needed.

Prenatal Weight Gain

Current weight gain recommendations from the Institute of Medicine are 11-20 lbs. for obese women, and 15-25 lbs. for overweight women.  However, many care providers these days are strongly pressuring obese women to diet to restrict weight gain, or even to deliberately lose weight during pregnancy.

This is a dilemma for women of size, because research suggests that very low gain or gestational weight loss may actually increase the risk of small-for-gestational-age or premature babies. Some research suggests differing weight gain recommendations for differing classes of obesity, but studies on limiting weight gain have many design flaws, so providers must tread carefully to balance potential benefits and risks.

Another alternative is to take a Health At Every Size® approach. Good nutrition and regular exercise is promoted, but without the scale as a goal.  The finger-wagging, shaming approach of most dietary intervention is absent, and although particular weight gain goal ranges can be encouraged, good nutrition is put ahead of rigid goals. Many women with a long history of dieting find a Health At Every Size® approach very freeing because it still emphasizes healthy behaviors, but without the scale as judge and jury.

Weight gain among women of size is extremely variable. A lot depends on the woman’s individual circumstances. Differing amounts can be normal as long as you are eating nutritiously.

As one big mom notes:

Talk about weight gain, but explain that every body is different. Some people gain lots and have healthy babies. Some people gain very little or even lose and have healthy babies. Don’t focus on the scale, but on healthy eating and assure people their bodies will then do what they need to do.

Another mom agrees, saying, “Providers can get across the point that excellent nutrition is key to a healthy pregnancy and birth without making mom stress over it.”

Finding a Size-Friendly Caregiver

Finding a size-friendly caregiver is critical to having a positive birth experience. Unfortunately, bias and mistreatment are not uncommon. Some of it is egregious mistreatment, while other examples show a more subtle bias.  In particular, many well-meaning care providers overutilize interventions in the labors of women of size.

Research shows that obese women are induced at much higher rates, experience a higher rate of interventions, and that caregivers have a lower threshold for surgical intervention in their labors. Although it is commonly believed that obesity predisposes to a cesarean, recent research suggests that cesarean rates can vary dramatically within the same weight class, depending on how the labor is managed.  This suggests that labor management and attitudes may be more of a factor in c-section rates than obesity itself.

High-BMI women need to ask careful questions about special protocols they may be pressured into (like early inductions for suspected macrosomia, early amniotomy, internal monitoring, or early epidurals) and how much wiggle room there is for working around these.

 One plus-sized postpartum nurse states bluntly:

As far as labor, the best advice I could give another [plus-sized] mom is to STAY MOBILE!!!!! Staying in bed, getting an epidural too soon, not being able to change positions frequently [equals] dysfunctional labor and c-section.

Other tips for lowering an obese woman’s chances for a cesarean can be found here and here.

Like other women, women of size need information on patient rights, how to advocate for themselves, their right to decline procedures, and information on filing a complaint if needed.  Knowing that they have the right to stand up for themselves and say “no” is a new concept to far too many plus-sized women.

Pay Attention to Fetal Position

There is some research and anecdotal evidence that suggests that women of size have a higher rate of malpositioned babies, and that this may play a role in their increased cesarean rate. Talk with women about fetal position, discuss ways to promote optimal fetal positions, and mention the possibility of chiropractic adjustments for those who are interested.

Since some very heavy women have pendulous bellies which may make it harder for the baby to engage in the pelvis, include some information about the “abdominal lift and tuck” exercise, as well as other positions that can help babies to engage during labor.

Birthing Positions for Women of Size

Encourage women of size to experiment with finding useful laboring and birthing positions that work with their bodies. Remember that like all women, women of size will vary in how athletic and flexible they are. Explore each position without judgment.

Many women of size find the all-fours position or a forward-leaning kneeling position useful. If the woman has an epidural, side-lying can be extremely helpful. Although “soft tissue dystocia” is an unproven concept, if there is any question of pelvic capacity frequent position changes and asymmetric positions like lunging may be helpful.  A birth ball (appropriate for height and weight) can also help relax the perineum, open the pelvis, and allow easier rotation among positions.

Many women of size report loving laboring in water. The buoyancy of the water allows position changes with greater ease, and eases pressure on the knees. The pain-relieving effect of water is another bonus, since epidurals can be harder to place in larger women.

Further information (and pictures) on birthing positions for women of size can be found here and here. Some care providers actively discourage mobility in women of size, so having a supportive caregiver is key. Practice multiple positions beforehand, emphasize the importance of frequent position changes, and promote having a labor support person who can help women utilize position changes more easily.

Summary

Although women of size are more at risk for certain complications, remember that women of all sizes can experience complications. All women benefit from the same basic advice for excellent nutrition, regular exercise, reasonable weight gain, choosing good providers, attention to fetal position, and use of flexible birthing positions. Emphasize proactive health behavior across the board.

What has been your experience in helping prepare women of size for birth?  How have the women you might have had in your classes or practice found the experience of pregnancy and birth as a large sized woman?  Do you have suggestions to add about your observations and favorite resources? Please share with our community.- SM

Plus-Sized Resources

Finding Size-Friendly Care

http://www.cat-and-dragon.com/stef/Fat/ffp.html – size-friendly providers of all types
http://plussizebirth.com/plussizedoulaconnections – size-friendly doulas
http://plussizebirth.com/midwife-ob-gyn-connections – size-friendly midwives and OBs
http://www.aafp.org/afp/2002/0101/p81.html – guidelines from the American Academy of Family Practitioners for improving care for obese patients
www.amplestuff.com – catalogue with products sized for larger people, such as larger blood pressure cuffs, scales that go to higher weights, larger exam gowns, etc.

General Size Acceptance and Health At Every Size® Resources

http://www.jonrobison.net/Health_Every_Size.pdf – pamphlet on Health At Every Size®
http://healthateverysizeblog.org/ – blog about Health At Every Size® issues
www.sizediversityandhealth.org – Association for Size Diversity and Health
www.cswd.org – Council on Size and Weight Discrimination
http://www.lindabacon.org/HAESbook/excerpts.html – info on Health At Every Size®
http://danceswithfat.wordpress.com/blog/ – size acceptance and Health At Every Size®
http://www.healthyweight.net/cntrovsy.htm – Healthy Weight Network
www.naafa.org – National Association to Advance Fat Acceptance
http://www.cat-and-dragon.com/stef/Fat/ffp2.html – tips on obtaining good health care
http://www.fwhc.org/health/fatfem.htm – Large Women’s Healthcare Experiences

Books on Health At Every Size®

• Bacon, Linda. Health at Every Size: The Surprising Truth About Your Weight. BenBella Books, 2010.
• Campos, Paul. The Obesity Myth: Why America’s Obsession With Weight is Hazardous To Your Health, Gotham Books, 2004.

 About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, informed Consent, Maternal Obesity, Series: Welcoming All Families, Uncategorized , , , , , ,

Welcoming All Families Series: Welcoming Women of Size In Your Birth Classes

November 6th, 2012 by avatar

Continuing along in our occasional series on “Welcoming All Families” to our childbirth classes, this two part guest post is written by Pam Vireday,  creator of the Well-Rounded Mama blog.  Are your childbirth classes friendly to women of size?  What special accomodations and resources do larger-sized mothers-to-be need if any? In today’s post, Pam discusses a check list of items that you might consider when teaching childbirth classes and on Thursday, Pam shares how to promote in your classes optimum outcomes at the births of these mothers.- Sharon Muza, S&S Community Manager

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MatthiasKabel GFDL www.gnu.org/copyleft/fdl.html Wikimedia Commons

Although the exact numbers vary according to the source used, it is no secret that many women of childbearing age are “overweight” or “obese”* by government standards.  This means that, sooner or later, most doulas, childbirth educators and health care providers will have women of size as clients or patients.

Many birth professionals are unsure of how to address the unique needs of this group. At a time when the media messages around obesity and pregnancy are almost uniformly negative and scare-mongering, it is important that birth professionals create a place for women of size to discuss their unique concerns without judgment.

Terminology*

Research shows that many larger people find the terms “obese” and “overweight” stigmatizing. Although size-acceptance activists prefer the word “fat,” some people cannot hear this term neutrally, and euphemisms like “fluffy” can feel patronizing.

Birth professionals are encouraged to notice and adopt the terminology used by clients for themselves. Until then, use more neutral terms like “plus-sized” or “women of size.” (Further discussion of the relative merits of various terms can be found here.)

Create a Safe Space

Most larger women have been negatively judged by others for their weight, and the disapproval is never stronger than when they consider pregnancy. Women of size need a non-judgmental space where they can feel free to discuss their concerns for pregnancy without being shamed, lectured to, or made to feel like “bad mothers.”

Your job as a birth professional is to create this safe place. Examine your own biases about weight, eating, and health.  Question your assumptions and engage with each woman as an individual. Utilize reflective listening, assist them in researching special issues, and neutrally explore proactive behaviors that might help address their concerns.

Make Sure Facilities Are Size-Friendly

Ask yourself ─ are your facilities friendly to larger bodies?  Do you have armless chairs? Seating that is easy to get up from?  Restrooms that accommodate larger people?  Comfortable facilities set the tone for a space that is welcoming to all sizes.

Remember that getting up and down from the floor can be difficult for many women in pregnancy, not just heavier women.  Have a few low stools around that women can use to help boost themselves up.  Also be sure your birth balls are appropriate for heavier women; a little higher and a little more heavy-duty balls can be helpful.

Address Special Equipment Needs

The correct blood pressure cuff size is vital for larger people.  A too-small cuff can artificially inflate blood pressure readings and result in unnecessary intervention.

According to guidelines from the American Heart Association, people with upper arm circumferences above about 13.4 inches (34 cm) need a “large adult” cuff, while those with a circumference above about 17.3 inches (44 cm) need a “thigh” cuff.  If in doubt, measure the client’s arm and cross-check it against the reference range printed on the BP cuff.

Some care providers resist using larger cuffs, so women or their support people may need to be quite assertive about utilizing the correct cuff size.

Discuss Breastfeeding When Well-Endowed

Some high-BMI women are quite well-endowed. This can present special challenges in breastfeeding, yet many women receive no information on how to meet these challenges. Cover a variety of nursing positions and techniques, including the football hold, which may be more useful for well-endowed women.

Have Additional Resources Available for Women of Size

A consistent problem for women of size is the difficulty in finding resources for their specific needs. For example, finding maternity clothes or a nursing bra in a larger size can be a major problem. Many women appreciate having a list of companies that specialize in plus-size maternity products.

Address Potential Risks and Complications

While the possibility of complications must be acknowledged, remind women that having a risk factor for a complication does not inevitably mean developing that complication. An individual’s outcome cannot be predicted by risk factors alone. Treat women of size like any other pregnant woman by expecting normalcy as much as possible.

Share websites that examine weight-related research with a neutral, critical eye, which acknowledge that complications are possible and promote proactive prevention, but which also point out that larger women can and do have normal, healthy pregnancies and births.

Find Positive Images and Stories of Women of Size

photo courtesy of Diaz Family

Media images of heavy people in our society are highly stigmatizing.  Most pictures of fat people are headless (dehumanizing them), unflattering (focusing on bellies or behinds in tight clothes), or reinforce stereotypical behavior (eating junk food or being sedentary).

Media discussions of pregnancy and obesity focus only on the risks for complications, tell apocryphal stories of worst possible outcomes as if they are commonplace, or compare fat pregnancy to child abuse.

Books that focus on obesity and pregnancy pay lip service to being size-friendly, but contain a preponderance of negative stories, highly-interventive births, and scare tactics about complications.  As one doula reviewer on Amazon wrote, “More time was spent telling me how much more likely I am to have a cesarean than to tell me how I can best avoid one.”

It’s very important to counteract these negative messages and images with positive ones.  Direct your client to websites which have plenty of positive images of women of size pregnant, giving birth, and breastfeeding (see list below).  Connect them with a community of like-minded women if they are interested.

Respect Patient Autonomy

Different people will look at the same information with differing values and make varying choices.  The same is true for women of size.  Some will respond to information about obesity-related risks by choosing a more-interventive childbirth model, and some will respond by choosing a less-interventive model.  Neither choice is right or wrong. Respect each person’s right to choose for themselves.

 

“All in all I think I just want to be treated the same as anyone else. Give me the information, not opinions, not value judgments. Let me decide what to do with it. Give me all the information, not what you perceive or decide I need. Treat me as thinking adult. Treat me with respect. Don’t belittle me, and do not treat me with kid gloves either.” Lexi Diaz, plus-sized mother of four.

Do you do anything different when women of size attend your classes?  Do you feel like your classes already accomodate any special needs they might bring? Do your visual aids and resource lists include pictures of women of size and resources designed for their needs?  Do you feel that any woman of size attending your class feels welcome or alone?  What have been your experiences with larger sized women taking your classes or being your client or patient.  Let us know your experiences in the comments section and share additional resources if you would like.  Read on Thursday, when Pam shares how CBEs can help women have optimum outcomes at their births.- SM

Plus-Sized Resources

Plus-Sized Pregnancy Information

www.wellroundedmama.blogspot.com
www.plus-size-pregnancy.org
http://www.facebook.com/theamplemother
www.plussizebirth.com
www.facebook.com/plussizemommymemoirs
http://pregnancy.about.com/od/plussizepregnanc/Plus_Size_Pregnancy.htm
http://www.facebook.com/pages/Plus-Maternity-Australia/107067319323331
www.fertilityplus.org
http://community.babycenter.com/groups/a425315/plus_size_and_pregnant

Finding Maternity Clothing in Plus Sizes

Plus-Size Maternity Clothing FAQ – help for finding maternity clothing, nursing clothing, nursing bras, and maternity-related products in plus sizes, both in the U.S. and abroad
http://plus-size-pregnancy.org/BBWBabyCarriers.html – help for finding baby carriers and slings in plus sizes
www.plusmaternity.com.au – resources on plus-sized maternity and nursing clothing in Australia
http://plussizebirth.com/2012/04/babywearing-for-the-plus-size-mom.htm – info on finding baby carriers for plus sizes

Positive Images of Plus-Sized Pregnant Women

*Do not use any of these photos without asking permission first

Plus-Sized Pregnancy Photo Gallery – series of blog posts with many pictures of plus-sized pregnancy and birth
Plus-Sized Pregnancy Breastfeeding Gallery – pictures of women of size breastfeeding
http://plussizebirth.com/gallery- gallery of plus-sized baby bumps, birth pictures, breastfeeding pictures, and babywearing pictures
http://oneyawn.blogspot.com/2012/06/belly-pictures-baby-number-three.html – belly diary of a plus-sized mom, week to week in pregnancy
http://www.facebook.com/theamplemother/photos_stream – plus-sized pregnancy photos
http://birthislife.blogspot.com/2012/08/nursing-portrait-session.html – lovely breastfeeding photos of a woman of size
http://www.yaleruddcenter.org/press/image_gallery.aspx – free for educational purposes with attribution to the Rudd Center for Food Policy and Obesity (no pregnancy images)

Birth Stories of Plus-Sized Women

http://www.plus-size-pregnancy.org/BBWBirthStories/bbwstrindex.html – stories with a wide range of outcomes and experiences
http://www.plus-size-pregnancy.org/BBWBirthStories/bbwvagnlstories.htm – stories of normal vaginal births in women of size
http://www.plus-size-pregnancy.org/BBWBirthStories/bbwspecvagstories.htm – stories of normal vaginal births in women of size despite special circumstances

About Pam Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

 

 

Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Obesity, Maternal Quality Improvement, Maternity Care, Series: Welcoming All Families , , , , , , , , ,

A Follow Up: Maternal Obesity from All Sides

November 7th, 2011 by avatar

Science & Sensibility readers may recall the Maternal Obesity from all Sides series* we did a few months ago.  Last week, while walking my dog and catching up on a few news podcasts, I heard this story on NPR’s Morning Edition—a segment that was a part of the news outlet’s series on Obesity in America.  The story discusses new research that looks at why it can be so difficult to lose and keep weight off from a hormonal and biological perspective.  The gist of the research referenced in this news piece is that when we concertedly work to lose weight, our body produces less of the hormone leptin (a natural appetite suppressant) which prompts a starvation signal in our brain, telling the body to conserve energy by decreasing metabolism and, at the same time, feel more hungry—prompting increased caloric intake.

Additionally, the Morning Edition segment made the point that once a person has gained more weight than that which is healthy for his/her stature, it becomes harder and harder to lose and keep the weight off.  As the reporter summarizes, “lower metabolism lasts a lifetime.”  (Despite this, some excellent points are later made in the segment which suggest that moderate exercise six days a week—such as brisk walking, swimming or cycling, can have positive effects on weight loss and maintenance.)

What does all this have to do with maternity care issues?

Well, in the Maternal Obesity from all Sides series, we discussed the growing correlations between maternal overweight and pregnancy and L&D outcomes:  how women of size are more likely to experience gestational hypertension and diabetes; how they are more likely to be offered labor inductions and undergo cesarean deliveries as a result of those comorbidities—whether or not those procedures are actually evidence-based for the given situation(s).  And we also discussed how addressing size and/or weight once a woman is pregnant is both unfruitful and unfair—because most of us recognize that pregnancy is not a time when a woman should be attempting to lose weight.  Likewise, it is not a time when a woman should be shamed for a preexisting condition (as if shaming is ever acceptable).

But, in the spirit of preventative care, I felt the NPR piece was enlightening: while there are MANY opportunities to improve maternal outcomes through preconception/interconception care, as pointed out in the recent blog post by Christine Morton, and the more distant series by Walker Karraa, perhaps working to prevent obesity in the first place—rather than focusing on after-the-fact individual or public health weight loss programming—is a better approach.  Because, according to the news segment linked to above, once extra weight has been acquired, losing and maintaining that weight loss is exceptionally more difficult.

A similar NPR story on All Things Considered aired just a few days earlier which covered this same topic and reviewed the findings of a study recently published in the New England Journal of Medicine.  The study by Priya Sumithran et al. assessed the hormone and metabolism changes that accompanied significant weight loss in severely calorie-restricted study subjects.  As described in the Morning Edition segment, Sumithran’s study described significant weight loss maintenance difficulties that were hormonally based.  In essence: maintaining weight loss is about hormones, not will power.

Women of childbearing age have enough maternity care-related challenges to face: escalating labor induction and cesarean delivery rates, racial disparities in access to care.  We talk a lot on this blog site about the cascade of interventions, a concept that is also frequently referred to in Lamaze teachings.  Perhaps it is time we should also be talking about a healthy cascade of prevention, with maternal obesity being a prime target.  Ideally this cascade of prevention begins well before women of childbearing age find themselves contemplating pregnancy, or preparing for birth.  But even as childbirth educators, we can play a part in this healthy cascade.  When covering postpartum topics, we can talk with our expectant parents about the importance of interconception health:  nutritious dietary choices and adequate exercise.  We can couch these discussions as approaches to optimizing health in various ways with various downstream benefits:  having adequate energy to play with one’s child(ren), reducing a family’s healthcare cost burden, and yes, laying the ground work for healthfully supporting a future pregnancy if and when that occurs.

As Dr. Miranda Waggoner stated in her interview with Dr. Morton, “…we do have to worry about viewing women as pregnancy vessels,” but I also think we need to begin looking at expectant women beyond just the here and now.

 

*The Maternal Obesity from All Sides series is also reviewed in the current Journal of Perinatal Education.  If you don’t already receive the JPE and would like to check it out, you can request a free copy of the journal here.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Maternal Obesity , , , , , , , , , , ,

Childhood Asthma and Maternal Factors: Have We Hit a Goldmine?

October 11th, 2011 by avatar

At two-years-old, our middle son underwent what would end up being a non-conclusive colonoscopy, in our attempts to diagnose the cause of his chronic diarrhea.  Around the same time, he suffered from eczema—an itchy, red skin rash that made him miserable, and sometimes kept him awake at night.  A year after all that, he was diagnosed with asthma—a condition that still plagues him, today.  Our youngest son, born at the same hospital as his older brother, also suffered from eczema.  His allergic skin rash was so severe that he was literally covered in itchy, red plaques from head to toe.

What Do Asthma and Birth Have in Common?
As we work to get our asthmatic son through the final weeks of allergy season—his breathing compromised by the mold spores currently in the air— I read with interest this article, recently published on Reuter’s Health web site.  The article discusses a new study by John Penders, et al out of the Netherlands which suggests a link between mode and location of birth, and a child’s subsequent risk of developing allergies and asthma later in life.  More specifically, the study looked at colonization of an infant’s gut with particular bacteria—E  coli and C difficile—and found a greater association with colonization of C diff. at birth, and subsequent atopy  later in life.

A soon-to-be published cohort study (in the same journal) by Adrian Lowe, et al. looked at another possible predictor of childhood asthma:  maternal obesity.  189,783 children born to 129,239 mothers in Stockholm Sweden between 1998 and 2009 were included in this study.  The study’s primary goal was to assess the relationship between early pregnancy maternal BMI and subsequent asthma later in life of the children—as judged by prescriptive asthma medication purchase and hospital admissions for asthma.

Statistical regression models revealed a linear relationship between increasing maternal BMI and incidence of offspring asthma—although from my reading of the study, the relationship appeared to be modest, according to the odds ratios provided in the study’s data.  Study authors conclude that, “If the association between maternal BMI and asthma risk in the child is causal in nature, it might explain between 11% and 13% of childhood asthma.”  (Emphasis, mine.)

Another recent cohort study, published in the Journal of Pediatrics (Tollånes, et al, 2008) looked at the association between cesarean delivery and incidence of childhood asthma.  This large (1,756,700 singletons) study out of Norway revealed a 52% increase in asthma incidence among children born via c-section, compared to vaginal delivery.

Application to Childbirth Education and Maternity Care
What do these studies and numbers mean for those of us working with expectant families?  Is it realistic to pin the burden of potentially “causing” her child’s subsequent asthma on a pregnant woman of size?  Is it realistic to think a laboring woman will contemplate her child’s possible risk of asthma, when faced with the potential of delivering via c-section?  No, I would argue, neither of those scenarios are terribly realistic.  But what I think these studies do point to is the importance of preconception counseling and guidance:  in the form of impressing upon people of childbearing age the importance of preconception good health (including a reasonable BMI for height, build and activity levels) and the continued importance of decreasing the overall cesarean section rate.

More and more studies continue to emerge—not just out of the maternity care research industry, but out of several research fields (pediatrics and asthma/immunology being two)—that point out the importance of normalizing birth practices whenever possible.  Ask any family who deals with the frightening circumstance of childhood asthma, and they will tell you:  if there had been something we could do ahead of time to prevent our (son/daughter) from developing respiratory disease…we would have done it.  Perhaps, we have landed upon a couple of significant opportunities within our own industry to decrease asthma prevalence and incidence.  I, for one, would be more than happy to aid in the decrease of childhood respiratory disease.  And my son, I think, would be happy about that, too.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

 

Cesarean Birth, Maternal Obesity, New Research, News about Pregnancy, Preconception Care, Research , , , , ,

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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