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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 , , , , , , , , ,

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

 

 

 

 

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

Maternal Obesity from All Sides

[Editor’s note:  in this  installment of our maternal obesity series, Dr. Kathleen Kendall-Tackett will guide us through a review of maternal obesity as it pertains to breastfeeding.  To read this series from the beginning, go here.  Tomorrow, we will finish up with some final thoughts from Well Rounded Mama’s, Pamela Vireday, on prevention strategies.]

I remember the moment quite clearly. I was at a large, international breastfeeding conference and stopped to read the research posters. As I did, I grew more and more irritated. There were several posters describing special interventions for “obese women.” Some of these interventions involved sending “obese women” to breastfeeding classes designed to address their “special” needs. Excuse me? First of all, the design of these studies appeared to assume that “obese women” are a homogeneous group, which they obviously are not. Second, why a class? Does the fact that they are heavy mean that they need special instructions? I’m certain that these colleagues meant well, but we have to ask whether this approach is a good idea.

OK, I’ll admit it: I’m a radical on this issue. My stand is due, in part, to the treatment that fat people—and fat women, in particular—receive in health care settings. The story goes something like this. Fat girl goes in for a medical exam because she’s been having concerning symptoms. Health care provider attributes all her health care problems to her size and sends her away with admonitions to lose weight. Only later, does it turn out that she has something awful, like cancer—a condition her HCPs missed completely because they made assumptions based on her physical appearance. Think I exaggerate? This scenario recently happened to the daughter-in-law of one of my friends.

Yes, but what about diabetes, heart disease, and the increased risk of complications following surgery, you might ask? Fortunately, I actually study diabetes, metabolic syndrome and heart disease. Obviously, health care providers do need to address any increased risk their patients might experience. So if their patients have high blood pressure, triglycerides, or LDL cholesterol, by all means address that. But we need to address those concerns without making sweeping assumptions about women who happen to have a higher BMI. For example, one colleague told me that she tells her obese patients that they need to lay off the soda and potato chips. The question I asked was whether she knew–for sure–that her fat patients were drinking soda and eating potato chips. Or that her slim patients weren’t? Did she know this or was she making assumptions based on prejudice against fat people?

Most of the proposed policy changes designed to address the “obesity epidemic” are, in my opinion, good ideas—for everyone, not just fat people. Get fast food and soda machines out of the schools? Great idea. Encourage more physical activity? Also good. Encourage increased consumption of whole grains, fruits and vegetables instead of highly refined and calorically dense junk food? Fabulous.

These approaches to obesity are all good. But we need to recognize a couple of things. First, even with all these interventions, some people are still going to be bigger than others. That isn’t necessarily a health problem. Second, someone can fall into the “obese” range on the BMI and still have good, sometimes even better cardiovascular health than someone who is smaller. Is size really an indicator of overall health, or is it perhaps simply one marker of many? Further, when someone brings up the issue of obesity to me, one of the first questions I ask in response is “how obese?” That makes a difference in terms of what type of problems we are likely to encounter. Assuming that all women who cross the “obesity” threshold have more health problems is simply wrong. Sometimes they do, sometimes they don’t. Third, providers sometimes assume that obesity is simply due to eating too much; that it’s just a matter of getting these women to take their faces out of the feeding trough. We’ve learned relatively recently, however, that it’s not quite that simple. In the past five years, there have been numerous studies demonstrating the role of depression, psychological trauma (particularly childhood abuse), and sleep disorders in weight gain and obesity. Yes, depression (and trauma and sleep problems) can make you fat. And there is also the matter of genetics. Some people are genetically programmed to be larger than others. Steps that these patients take to improve their health will improve their health. But these interventions may not significantly change their size.

So back to the question of a special breastfeeding gulag for fat girls. These interventions assume that women over a certain BMI will automatically have breastfeeding problems. When I’ve raised this issue with my colleagues, I’ve heard arguments about how larger breasts can cause problems, or that fat women have lower prolactin levels after birth.  They also assure me that fat women feel more shame about their bodies and will be reluctant to breastfeed when outside their homes, something we know is related to earlier breastfeeding cessation. OK, these things might possibly be problems. But women overcome breastfeeding problems all the time. The question we need to ask is whether we are creating self-fulfilling prophecies about these women. Breastfeeding is largely a confidence game. If we communicate to women that they think they will fail, whether we say this directly, or indirectly by sending them to a special class¸ are we setting them up for failure? This is a lesson we had to learn about mothers with issues such as flat nipples. Yes, these women can have more problems, but they don’t always. When we make flat nipples an issue, and communicate that mothers will likely fail, we can increase the rate of breastfeeding failure.

As for the shame issue, keep in mind that while there are discernable physical markers of obesity (such as BMI), obesity is also a social construct. Not everyone who is fat feels badly about it. In fact, in some ethnic minority populations, fat women are considered attractive. (And from an evolutionary standpoint, carrying some extra poundage is actually a survival advantage.) The question we need to ask is whether obese women with positive body images are having more breastfeeding problems than their smaller peers. I strongly suspect that they are not.

Frankly, it’s time for empowered fat girls to speak out on behalf of our sisters who do not yet know that they have a voice.  Women of size deserve respectful care, not shaming.  Is packing these women off to a breastfeeding fat camp a good idea?  Personally, I don’t think so. And I can’t imagine how you would market these classes to mothers. How many would willingly sign up for classes designated for obese women? (“Oh yes, that’s me. Please sign me up!”) While we want to proactively address any problems we think that these women may encounter, we need to plan our interventions with circumspection and care. Women of all sizes deserve no less.

Posted by:  Kathleen Kendall-Tackett, who is a health psychologist and board-certified lactation consultant. She is a clinical associate professor of pediatrics at the Texas Tech University School of Medicine in Amarillo, Texas. The views expressed in this posting likely do not reflect the official views of the Texas Tech

Maternal Obesity, Uncategorized , , , , ,

Maternal Obesity from All Sides (Part 6)

June 13th, 2011 by avatar

[Editor’s note:  In today’s post, sixth out of our eight-part series on maternal obesity, Pamela Vireday takes a closer look at the research surrounding pregnant women of size.  To read Pam’s first post, go here.  To read this series from the beginning, go here.]


Rethinking the Paradigm: An Insider’s View (Part Two)

Previously, we discussed the risks around obesity and pregnancy, and why they need to be communicated more compassionately and with a more precise sense of actual numerical risk.

Now let’s examine the research with a more critical eye.

 

Rethinking Research
One major problem with research on obesity and pregnancy is that it’s rarely analyzed for iatrogenic factors, which can have considerable effect. For example, how much of the increased cesarean rate in women of size is due to obesity itself, and how much is due to typical management protocols used on obese women or fears about their labors?

Many studies show that obese women are induced at higher rates than women of average size, even when they have no complications.  We know that induction (especially in first-time mothers) often increases the rate of cesareans. Yet almost no researchers connect the dots between a high rate of inductions in obese women and their increased rate of cesareans.

But are these inductions necessary?  Sometimes ─ but many are questionable.  For example, many obese women report being induced early because of the fear of a big baby getting stuck.  Obese women do have a higher rate of big babies, but most have average-sized babies (83% in one study).  Yet many doctors act as if they all will have big babies and act accordingly.

The practice of inducing early for suspected macrosomia does not improve outcome; it raises the cesarean rate and increases the risk for shoulder dystocia, the very thing doctors are trying to avoid.  A review of the issue found that “suspicion of macrosomia is not an indication for induction or for primary cesarean delivery.” Yet many providers disregard these guidelines, particularly with high-BMI women.

Just the expectation of a big baby strongly raises the rate of inductions and lowers the threshold for cesareans. In one study, the suspicion of macrosomia before labor raised the c-section rate from 16.7% to a whopping 57.1%. They found that the actual size of the baby itself had much less impact on the cesarean rate than the expectation that the baby would be big and the resulting management of labor.

Indeed, Graves 2006 found that the combination of obesity, macrosomia, nulliparity, and induction doubled the risk for cesarean section.  Wolfe 2011 found that women with a BMI of 40 or more without a previous vaginal birth and who carried a macrosomic fetus had an 80% rate of failed induction.  Clearly, the combination of suspicion of macrosomia and induction is a powerful factor driving the rate of cesareans in obese women.

Yet most macrosomic babies can be born vaginally when given the chance, and spontaneous labor is key.  Avoiding induction, encouraging mobility in labor and pushing, discouraging epidurals, and avoiding forceps/vacuum extraction might lessen the risk for shoulder dystocia in women of size.

Another iatrogenic factor in high cesarean rates in this group is the overutilization of interventions like internal fetal monitoring, pitocin augmentation, early amniotomy, and early epidurals.  Abenhaim and Benjamin 2011 showed that when interventions like pitocin use and epidurals were controlled for, the relationship between BMI and cesareans was markedly attenuated. Yes, labor progression in high-BMI women tends to be slower, but perhaps all that is needed is a tincture of patience instead of extra interventions.

They also found that doctors were far quicker to resort to cesareans in obese women, speculating that doctors fear that a heavier woman necessarily means a bigger baby that could get stuck in the birth canal.”  The authors conclude, “Because of the potential morbidities associated with Caesarean section, we must modify our management approaches to allow equal opportunity for vaginal birth for all women.”

However, many care providers now won’t even give high-BMI women a chance to labor at all, believing that vaginal birth is exceedingly unlikely and far too dangerous. Recently, the NHS in the United Kingdom conducted a study to see whether planned vaginal delivery or planned cesarean delivery was safer for super obese women (BMI >50).  An accompanying commentary admitted that it is

 

 

the frequently voiced opinion at midwifery, obstetric and anaesthetic conferences that the safest way to deliver a woman with a body mass index (BMI) over 50 kg/m2 may be by elective CS.

 


However, the authors found that when given the chance to labor, 70% of women with a BMI greater than 50 were able to give birth vaginally, without the “expected” increase in neonatal and postnatal complications.  This shows that very fat women can give birth vaginally if given an adequate chance, and in doing so, avoid the considerable risks associated with cesareans in obese women.

Confounding factors are not always accounted for in cesarean rate studies either. For example, doctors have tried to blame more dystocia in obese women on ineffective contractility, soft tissue dystocia or high cholesterol levels. However, Jensen 1999 found higher rates of persistent posterior babies in obese women; this is supported by anecdotal evidence that many women of size have cesareans for fetal malpositions. Since malpositions can cause longer labors, more interventions, and more cesareans, we need additional research to explore this possibility further.

Another confounding factor rarely accounted for in cesarean rate studies is the influence of menstrual cycle length and “postdates” pregnancies.  Research shows that women of size have longer menstrual cycles; perhaps this is why they have more “postdates” pregnancies.  Women whose cycles are only longer by a week or so fall into the “margin of error” in ultrasound dating and rarely have their due dates adjusted, but even a week can make a difference in how ready a woman’s body is for labor.

If these women are induced for “postdates” pregnancies when they are not truly postdates, then that may be another reason for a higher rate of failed inductions for postterm pregnancy in obese women. Perhaps the real story here is that these women’s bodies were not yet ready for labor due to longer menstrual cycles and unadjusted due dates.

There are only a few examples of iatrogenic and confounding factors that may be influencing outcomes in women of size.  Researchers must start becoming more cognizant of these and many others.

 

Looking For More Meaningful Research
The bottom line is that research on obesity in pregnancy needs to diversify.  Currently, the research contents itself with documenting increased complication rates and little more.  This is not without value, but its usefulness is limited.  We need to stop wringing our hands and clutching our pearls about the horrors of obesity and start doing more meaningful research.

We need more information on the cause of complications in obese women.  Remember, correlation is not causation.  Just because obesity is associated with certain complications does not mean it causes those complications.  Instead, the real problem may be an underlying metabolic or hormonal disorder (like Polycystic Ovarian Syndrome), and obesity may merely be a symptom instead of a cause.  This opens up many new possibilities for treatment, regardless of weight loss status.

Similarly, research on obesity and complications needs to ask deeper questions.  Many obese pregnant women never develop complications, yet rarely are studies done that compare the obese women with complications to those without.  Perhaps there are differences in metabolism or behavior that can explain differing outcomes, and if so, these could suggest further prevention strategies.

Recent research has shown that many obese people have multiple nutrient deficiencies, so some have speculated about the potential benefits of supplementation. For example, 400 mcg of folic acid is not protective against neural tube defects in obese women, so some obstetric organizations recommend a very high dose instead. Yet little actual research has yet been done to investigate the safety and efficacy of this possibility.

Women of size also have a much higher rate of vitamin D deficiency than other women, and vitamin D levels have been tied to higher cesarean rates, more gestational diabetes, and more hypertension. Perhaps supplementation or more sun exposure might help lower these risks.

And given the research on how high-intervention care affects outcome in obese women, it is especially important to examine the recent trend to deny high-BMI women access to low-intervention care.  Perhaps low-intervention care models actually achieve better outcomes in women of size ─ but we won’t know unless we study it.

These are only a few areas of research to explore; there are many other possibilities as well. We need to stop stumbling around in the dark with blinders on, ignoring iatrogenic and confounding factors and operating on sheer guesswork as to what will improve outcomes.  It’s time for research on this topic to stop its simplistic approach and start asking more meaningful questions.

Additional References and Links:

Subject Studies and Links
Cesarean Rate in Obese Women Chu 2007 http://www.ncbi.nlm.nih.gov/pubmed/17716296 

Vahratian 2005 http://www.ncbi.nlm.nih.gov/pubmed/15921926

Poobalan 2009 http://www.ncbi.nlm.nih.gov/pubmed/19021871

Induction and Obesity Jensen 2003 http://www.ncbi.nlm.nih.gov/pubmed/12861169 

Graves 2006 http://www.ncbi.nlm.nih.gov/pubmed/16814219

Bhattacharya 2007 http://www.biomedcentral.com/1471-2458/7/168

Michlin 2000 http://www.ncbi.nlm.nih.gov/pubmed/10892363

Pevzner 2009 http://www.ncbi.nlm.nih.gov/pubmed/19935035

Wolfe 2011 http://www.ncbi.nlm.nih.gov/pubmed/21621187

Induction and Cesareans Dunne 2009 http://www.ncbi.nlm.nih.gov/pubmed/20085677 

van Gemund 2003 http://www.ncbi.nlm.nih.gov/pubmed/14530612

Vardo 2011 http://www.ncbi.nlm.nih.gov/pubmed/21366123

Macrosomia and Obesity Bhattacharya 2007 http://www.biomedcentral.com/1471-2458/7/168 

Ehrenberg 2004 http://www.ncbi.nlm.nih.gov/pubmed/15467573

Narchi and Skinner 2010 http://www.ncbi.nlm.nih.gov/pubmed/20925609

Induction for Macrosomia, 

And Cesarean Rates

Leaphart 1997 http://www.ncbi.nlm.nih.gov/pubmed/9086425 

Melamed 2010 http://www.ncbi.nlm.nih.gov/pubmed/20103792

Parry 2000 http://www.ncbi.nlm.nih.gov/pubmed/10664942

Zamorski and Biggs 2001 http://www.ncbi.nlm.nih.gov/pubmed/11201695

Sanchez-Ramos 2002 http://www.ncbi.nlm.nih.gov/pubmed/12423867

Induction and Shoulder Dystocia Jazayeri 1999 http://www.ncbi.nlm.nih.gov/pubmed/10214826 

Combs 1993 http://www.ncbi.nlm.nih.gov/pubmed/8459954

Obesity and Menstrual Cycle Length Symons 1997 http://www.ncbi.nlm.nih.gov/pubmed/9074747 

Kato 1999 http://www.ncbi.nlm.nih.gov/pubmed/10608360

Obesity and Postdates Pregnancy Graves 2006 http://www.ncbi.nlm.nih.gov/pubmed/16814219 

Sarkar 2007 http://www.ncbi.nlm.nih.gov/pubmed/17963180

Interventions in Obese Labors Ray 2008 http://www.ncbi.nlm.nih.gov/pubmed/18569473 

Andreasen 2004 http://www.ncbi.nlm.nih.gov/pubmed/15488115

Jensen 1999 http://www.ncbi.nlm.nih.gov/pubmed/10535344

Roofthooft 2009 http://www.ncbi.nlm.nih.gov/pubmed/19412095

Soens 2008 http://www.ncbi.nlm.nih.gov/pubmed/18173431

Abenhaim 2011 http://www.ncbi.nlm.nih.gov/pubmed/21639963

More Difficult Labors/Labor Dystocia Vahratian 2004 http://www.ncbi.nlm.nih.gov/pubmed/15516383 

Walsh 2011 http://www.ncbi.nlm.nih.gov/pubmed/21158492

Arrowsmith 2011 http://www.ncbi.nlm.nih.gov/pubmed/21265999

Possible Reasons for More Labor Dystocia in Obese Women Higgins 2010 http://www.ncbi.nlm.nih.gov/pubmed/19828431 

Jie Zhang 2007 http://www.ncbi.nlm.nih.gov/pubmed/17913965

Wischnik 1992 http://www.ncbi.nlm.nih.gov/pubmed/1290280

Barau 2006 http://www.ncbi.nlm.nih.gov/pubmed/16972860

Risks of Cesareans in Obese Women Chisaka 2004 http://www.ncbi.nlm.nih.gov/pubmed/14698829 

Alanis 2010 http://www.ncbi.nlm.nih.gov/pubmed/20678746

Vricella 2010 http://www.ncbi.nlm.nih.gov/pubmed/20673866


Posted by:  Pamela Vireday, who 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 16 years. She writes at www.plus-size-pregnancy.org and blogs at www.wellroundedmama.blogspot.com.

Maternal Obesity, Uncategorized , , , , , ,

Maternal Obesity: A View from All Sides

June 10th, 2011 by avatar

[Editor’s note:  The next three posts are brought to you by Pam Vireday, creator of the Well Rounded Mama blog.  To read this eight-part series on maternal weight issues from the beginning, go here.]

 


Rethinking the Obesity Paradigm: An Insider’s View (Part One)
The topic of obesity and pregnancy is being written about more and more in the medical literature and the popular media.   The tone of these stories, however, has changed over the years to become ever more sensationalistic. There is so much gloom and doom information that sometimes it sounds as if no obese* woman has ever had a normal pregnancy or a healthy baby, which of course is not true at all.

What’s missing is a sense of perspective around the risk for complications; what is the real risk of experiencing that complication? How many obese women will not experience it?  How can we communicate risk information to women without sensationalizing it or presenting it in a shaming way? How does the tone of these stories reflect the moral narrative we have set up around obesity in our society?

Second, research articles rarely have any critical discussion of confounding or iatrogenic factors.  Instead, they tend to be simplistic litanies of risk rather than thoughtful examinations of outcomes.  How can we make obesity and pregnancy research more meaningful, and what new directions of investigation should be pursued? And given the spectacular failure rate of most weight loss efforts, can we find alternate methods of risk mitigation?

But the most conspicuous missing piece in these discussions is the voice of ordinary women of size and their lived experiences of pregnancy and birth.  Women of size are weary of being lectured at but not listened to; we want to share our own experiences about what worked in our care, how we were treated, what our challenges and special needs are, and what we want from our care providers.  The voice of women of size is an important missing part of so much of the discussion on this topic.


Rethinking Communication about Risks

One of the most difficult tasks for care providers regarding obesity and pregnancy is how to discuss the risk of complications in obese women accurately yet sensitively.

Many studies point out the increased rate of complications in obese women.  As other posts in this series have discussed, there is strong evidence that obese women are at increased risk for gestational diabetes, pre-eclampsia, macrosomia (big baby), cesareans, medically indicated pre-term birth, and birth defects and these risks appear to escalate with increasing levels of obesity. In addition, there is research that obese women are also at increased risk for miscarriage, urinary tract infection, postpartum hemorrhage, blood clots, stillbirth, and maternal mortality.

Yes, there are risks to pregnancy at larger sizes, and some high-BMI women do experience complication. But the fact is that these risks, while not negligible, are not universal either. The truth is that many women of size have healthy babies without complications ─ but you’d never know that from reading media articles or medical literature.

Yes, we should discuss possible risks; that’s an important part of the healthcare conversation. However, instead of fair and balanced counseling about risk, some care providers have become “Scare Providers” instead.  And that’s not effective or helpful.

As reported on my blog and other blogs, some obese women report that they aren’t just being told about their increased risk for complications, they’re being told that they will get that complication; some are told to just schedule their cesarean from the beginning of their pregnancy. Some women of size have been told that if they get pregnant they’ll surely die, that they’re committing suicide by pregnancy, that their baby will have only a 5% chance of survival, that their baby will be deformed, that they should abort their baby because it would never survive anyhow, or that they better make funeral arrangements before their cesarean.

Because of our society’s dogged belief that obesity is all about willful sloth and gluttony, communication about risks has taken on an ominous moral overtone. Some media commentators imply that if the mother would only show a little self-control, she could stop irresponsibly putting her baby at risk.  Some portray fat mothers as despicable food addicts, akin to drug addicts and alcoholics, endangering their babies with their addiction.  Some imply that obesity during pregnancy is equivalent to child abuse.  Often an apocryphal story of an obese woman with severe complications is trotted out as a cautionary tale, implying that all fat women are at equal risk for such a dire outcome, and that anyone who dares to be pregnant while fat is the ultimate Bad Mother. Or as one blogger puts it, “fat is the new crack” in bad-mother blaming.

Such fat-shaming tactics backfire in the long run.  The hyperbole around risk can become so extreme that many obese women stop listening, tune out the lectures, or avoid medical care entirely. Few things frustrate women of size more than medical bullying, and a common defense against it is avoidance.  If care providers want their message to be heard, fat-shaming is not the way to do it.

Another problem with obesity public health campaigns is that they don’t provide enough perspective around the risks. Mental inflation of risk occurs because many researchers use odds ratios instead of actual numerical risk.  For example, some studies have found 2-4 times the risk for Neural Tube Defects (NTDs) in obese and morbidly obese women.  Sounds scary, doesn’t it?  Yet rarely do the studies or articles mention that double or even quadruple a very small risk (about 1-2 per thousand) is still a very small risk. Do the math. Even if there is an increased risk, less than 1% of obese women will probably have a baby with a NTD.

Odds ratios inflate the sense of risk while obscuring the fact that the actual numerical risk for a complication is relatively low. It doesn’t mean that increased odds for a complication is meaningless; that does still have meaning and needs to be paid attention to. But it’s important not to overreact to it either.

Gestational Diabetes is another area in which risk gets amplified by the way it is presented. Many large studies find that the risk for GD hovers around 10-15% or so in morbidly obese or super obese women. This is compared to a risk of about 2-5% in the non-obese population, so it definitely is an increase in risk. However, it also means that about 85-90% of these women will not experience this complication.  Do you come away from articles on obesity and pregnancy with the impression that more than three-fourths of very fat women will not be diagnosed with gestational diabetes?

It’s important that care providers explain that when they say a certain group is more “at risk” for a certain complication, it doesn’t mean that all or even a majority of the group will experience that complication, nor does it predict individual outcome at all. Again, actual numerical estimates are helpful in putting the risk in perspective.

So how does a care provider or childbirth educator discuss risk with a woman of size?

First, don’t forget to mention that many women of size have normal pregnancies, births, and babies. This is information that is rarely mentioned but is deeply appreciated by women of size.

Second, compassionately present information about possible risks, using both odds ratios and actual numerical risks in order to place things in perspective.

Third, be sure to let the woman know that if she develops a complication, it doesn’t mean she’s a “bad” mother, that there are treatments available to try to minimize problems associated with that complication, and that women of all sizes experience complications.

Finally, emphasize the proactive things that women of size can do to minimize their risk of complications. (More on this soon.)

Knowledge is power. Yes, there are risks to obesity and pregnancy, but it’s important to know the real magnitude of those risks, and to know that if complications occur, they are usually manageable with supportive care.  More importantly, it’s helpful to know that proactive action may help mitigate the risks; this leaves women much more hopeful than when risks are presented without such context.

Women of size deserve to be informed consumers. They deserve accurate information about the potential risks; they deserve to hear it without scare tactics or shaming; and they deserve information about how to be as proactive as possible in minimizing these risks. Care providers need to do a better job of communicating this information non-judgmentally or risk women not listening at all.

 

Subject Links
Stories of Bias Third Annual Turkey Awards: Jumping To Conclusions” 

You’re Going To Have To Get A Cesarean Section Because Of Your Weight

If You Get Pregnant, You Will Get Gestational Diabetes, Have High Blood Pressure…and…Die

You Wouldn’t Make It Because You Are Puffed Out and Tired

You Are Short of Breath Because You Are Overweight

Please Document Your Stories of Mistreatment

Suicide by Pregnancy?”

Gina Marie’s Story

Pressure for Abortion for Obese Women

First Annual Turkey Awards

Fat Pregnancy Equals Death?”

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

Risks of Obesity and Pregnancy: Summaries Sebire 2001 http://www.ncbi.nlm.nih.gov/pubmed/11477502 

Bhattacharya 2007  http://www.biomedcentral.com/1471-2458/7/168

Owens 2010 http://www.ncbi.nlm.nih.gov/pubmed/20067952

Joy 2009 http://www.ncbi.nlm.nih.gov/pubmed/19067282

Jarvie and Ramsay 2010 http://www.ncbi.nlm.nih.gov/pubmed/19880362

Tsoi 2010 http://www.ncbi.nlm.nih.gov/pubmed/20971713

Birth Defects Rasmussen 2008 http://www.ncbi.nlm.nih.gov/pubmed/18538144 

Waller 1994 http://www.ncbi.nlm.nih.gov/pubmed/8116710

Shaw 1996 http://www.ncbi.nlm.nih.gov/pubmed/8601928

Stothard 2009 http://www.ncbi.nlm.nih.gov/pubmed/19211471

Blomberg and Källén 2010 http://www.ncbi.nlm.nih.gov/pubmed/19711433

Gestational Diabetes Torloni 2009 http://www.ncbi.nlm.nih.gov/pubmed/19055539 

Roman 2011 http://www.ncbi.nlm.nih.gov/pubmed/21366395

Catalano and Hauquel-De Mouzon  2010 http://www.ncbi.nlm.nih.gov/pubmed/21288502

Kim 2010 http://www.ncbi.nlm.nih.gov/pubmed/20395581

Pre-Eclampsia Duckitt and Harrington 2005 http://www.ncbi.nlm.nih.gov/pubmed/15743856
Macrosomia Ehrenberg 2004 http://www.ncbi.nlm.nih.gov/pubmed/15467573
Cesareans Chu 2007 http://www.ncbi.nlm.nih.gov/pubmed/17716296 

Poobalan 2009 http://www.ncbi.nlm.nih.gov/pubmed/19021871

Weiss 2004 http://www.ncbi.nlm.nih.gov/pubmed/15118648

Prematurity Smith 2007 http://www.ncbi.nlm.nih.gov/pubmed/17138924
Morbid or Super Obesity Cedergren 2004 http://www.ncbi.nlm.nih.gov/pubmed/14754687 

Mantakas and Farrell 2010 http://www.ncbi.nlm.nih.gov/pubmed/20732737

Mbah 2010 http://www.ncbi.nlm.nih.gov/pubmed/20482533

Miscarriage Lashen 2004 http://www.ncbi.nlm.nih.gov/pubmed/15142995
Blood Clots Larsen 2007 http://www.ncbi.nlm.nih.gov/pubmed/17257657
Stillbirth Nohr 2005 http://www.ncbi.nlm.nih.gov/pubmed/16055572

 

 

 

Posted by: Pamela Vireday, who 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 16 years. She writes at www.plus-size-pregnancy.org and blogs at www.wellroundedmama.blogspot.com.

Maternal Obesity, Uncategorized , , , , , ,