Posts Tagged ‘maternal obesity’

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


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.


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


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.


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


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 8th, 2011 by avatar

[Editor’s note:  This is the third in a series of seven posts on maternal obesity.  If you missed the first two installments, go here to begin reading.]


The CA-PAMR (PAMR) points to disparities in maternal outcomes by ethnicity and in conjunction with weight categorization:

“Obesity among the women who died from pregnancy-related causes was fairly evenly distributed by age and did not differ significantly by insurance type. However, greater proportions of African-American (83%) and U.S.-born Hispanic (80%) women who died were either overweight or obese at the beginning of pregnancy compared to Whites (50%), foreign-born Hispanics (44%), and Asian/Pacific Islanders (20%). African- American women had significantly higher mean BMI (mean=32.6) than foreign-born, Hispanic women (mean=25.5) (p<0.05), but did not significantly differ from the other racial/ethnic groups (range of means=25.9 – 31.0).” (2011 CA-PAMR, pg. 32)

The difficult to digest conclusion made in the report is that of the 98 pregnancy-related maternal deaths (2002-2003) analyzed in the PAMR, 60% (n=58) of those women were overweight or obese.  Due to confidentiality, specific characteristics linked to each woman who died are not relayed in the report, so we can only postulate on how much of those maternal deaths in women of size were directly correlated to their weight.


Cardiovascular disease, including cardiomyopathy (20%)
Pre-eclampsia/eclampsia (15%)
Amniotic fluid embolism (14%)
Obstetrical hemorrhage (10%)
Sepsis/infection (8%)

In the ensuing Recommendations section, the report goes on to advise:

“Practice guidelines and best practices for the preconception management of obese women need to be established, as well as for management of gestational weight gain.

“National and State education campaigns should target adolescents and women of child-bearing age to promote attainment of a healthy pre-pregnancy weight and appropriate weight gain during pregnancy through better nutrition and increased activity.”

To me, this advice is spot-on…and not just for California’s child bearing population, but for the provision of care for women of childbearing age, everywhere.  Accepting the status quo of increasing maternal overweight and obesity and patching together practice measures that are less than evidence-based is little more than a Bandaid approach.  And not always a very good one, at that.  Opting more frequently for labor induction or primary cesarean “just in case” places a whole heck of a lot of women at increased risk associated with those medical interventions which they may not even be candidates for.

But before going further down the path of preventative measures, I can’t leave out the justifiable concerns of maternity care providers:  The realities of caring for an obese or extremely obese pregnant woman can be extra-challenging:

•      Prenatal sonography in obese women is less accurate

•      Instrumentation available to maternity care providers may be inadequate

•      Assisting a poorly-mobile (due to epidural anesthesia) obese or morbidly obese woman from gurney to operating table can risk injury to nursing, care provider and other support staff

•      Excessive abdominal adipose tissue can make palpating fetal position/lie as a woman’s due date approaches difficult

•      During the (rare) need for a woman to be placed under general anesthesia (in a super-emergently necessitated c-section) intubation can be more difficult in an extremely obese individual

In her 2010 article, Obesity, risk and the challenges ahead for midwives, published in the British Journal of Midwifery (Vol. 18, Iss. 1, 01 Jan 2010, pp 18 – 23), Research Midwife Jo-Anne Irwin provides a list of equipment that a care provider should consider having on hand, to adequately care for a pregnant woman of size:

•      Hoists*

•      Heavy duty scales*

•      Higher working load

•      Extra width, beds, mattresses, [operating] tables and [gurneys]

•      Large blood-pressure cuffs

•      Extra long spinal needles, extra deep abdominal surgical instruments, extra large gowns

•      Large chairs and wheelchairs

•      Longer straps for fetal monitors

Once a large, pregnant woman presents for service, a doctor or midwife’s call is to care for her with the upmost compassion, knowledge and evidence-based practices possible.  Time cannot be reversed and comorbidities present must be dealt with.  And yet, Irwin makes the salient point in her article that I would like to finish with:

“A good starting point is the provision of preconception care, where dietary advice, weight management and activity levels could be discussed before pregnancy.”

Irwin goes on to reference guidelines recently published by the (British) National Institute of Health and Clinical Excellence (NICE), which offers advice for maternity care providers on weight management before, during and after pregnancy.  The emphasis here is on prevention.

The data on comorbidities associated with maternal overweight and obesity are extensive.  Obese women who become pregnant do have higher risks of developing certain complications compared to their normal weight counterparts.  This doesn’t mean that every overweight expectant mother will experience a dangerous or disastrous outcome—just as normal weight women are not 100% immune from pregnancy-related complications.  All women deserve compassionate and evidence-based perinatal care—large, small, or somewhere in between.  And yet, if we can take the steps to decrease the chances of developing certain risk factors–such as the recommendations for body weight and exercise guidance offered in the SOCG clinical practice guidance–why not put considerable effort toward that goal?

In a perfect, Wallgreens-esque world, here’s what I would love to see implemented within our women’s healthcare system:


•      Referrals to registered dieticians (or successful implementations of wildly popular community classes) for every woman of childbearing age with the goal of teaching teens and young women how to optimize their health, through dietary choices, well before becoming pregnant.

•      Referrals to group or individualized exercise programs for women who lack background understanding of healthy exercise options…before their first pregnancy

•      Implementation of healthy body weight discussions at every well-woman exam appointment.  This might include discussion of individualized genetic risk factors and socioeconomic issues that add a greater degree of challenge to the woman’s overall scenario

•      Implementation or promotion of community-based nutrition support programs for families that can’t afford to buy good, healthy food (and perhaps fall above the income level that dictates inclusion into the WIC program)

To the healthcare provider who responds, “I barely have enough time to get through the basic well-woman exam, let alone all that patient counseling,” I respond:  “Yeah, I get it.”  Fifteen minute appointments that optimize clinic efficiency and income generation don’t allow for this type of in-depth patient-provider interaction.  In the same token, if we can’t rearrange our patient scheduling and make time for preventative care, how can we expect issues, like the world-wide obesity epidemic to get any better?  We’ve got to go back to the drawing board, folks, and start caring for these mamas and their babies well before conception ever takes place.

*On a personal level, I would hope that any maternity care provider and/or facility would do everything in their power to avoid the use of such implements–purely from the perspective of maintenance of dignity.  Having heard stories of obese patients taken to a hospital’s loading dock for weight measurement on an industrial-sized scale holds the potential to be extremely damaging to a person’s self esteem.

[Tomorrow, you will hear from UNC-Charlotte Nursing Professor Kristen Montgomery, regarding dietary education in maternity care, and the sociocultural issues that come into play.  Following Kristen’s post, look forward to reading thoughts and evidence presented by Kmom, from The Well Rounded Mama.]

Posted by:  Kimmelin Hull, PA, LCCE

Maternal Obesity , , , , , , ,

cheap oakleys fake oakleys cheap jerseys cheap nfl jerseys wholesale jerseys wholesale nfl jerseys