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

November 8th, 2012 by avatar

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

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

Nutrition and Exercise

photo courtesy of Pamela Vireday

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

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

Nutrition Diaries

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

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

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

Prenatal Weight Gain

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

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

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

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

As one big mom notes:

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

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

Finding a Size-Friendly Caregiver

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

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

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

 One plus-sized postpartum nurse states bluntly:

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

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

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

Pay Attention to Fetal Position

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

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

Birthing Positions for Women of Size

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

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

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

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

Summary

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

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

Plus-Sized Resources

Finding Size-Friendly Care

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

General Size Acceptance and Health At Every Size® Resources

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

Books on Health At Every Size®

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

 About Pamela Vireday

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

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

 

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

Maternal Obesity from All Sides

June 6th, 2011 by avatar

[Editor’s note: This week and next on Science & Sensibility, we will discuss the issue of maternal obesity.  With increasing numbers of overweight and obese women approaching pregnancy, labor and birth, complication and intervention rates are sky rocketing in this population—in sometimes controversial ways.  This series of posts will attempt to answer the ultimate question:  how do we tenderly care for these women, employ evidence-based practices, and still support and honor normal birth whenever possible?]

Globesity:  A World-Wide Epidemic
Maternity care providers bemoan the increased risks associated with caring for overweight and obese pregnant women.  The recipients of their care feel unfairly judged, overly intervened-upon and ghettoized for their body habitus.  As this issue continues to grow, maternity care providers, doulas and childbirth educators need to find a way to interact with these women with equal amounts of compassion and scientific evidence.  And the evidence, in and of itself, is sometimes controversial.

As it turns out, maternal overweight and obesity isn’t just an American thing anymore.  The World Health Organization has made a surveillance tool available on their website, where you can view charts, graphs and maps detailing the rates of adult obesity by country.  Here in America, nearly 36% of adults are obese, including 1 out of 3 women.  The UK reports a similar rate, with 34% of adults considered obese, including 1 out of 5 women.  And pregnant American women are found to be obese 18-38% of the time.

While different countries sometimes use different methods to categorize weight status, the Body Mass Index calculator is most commonly employed:

 

The problem with using BMI as a body weight categorization tool, is that it does not take into account bony structure, muscle mass or percentages of lean mass compared to adipose tissue.  At best, Body Mass Index is a crude measure of health.  However, academic literature that analyzes weight in relation to pregnancy outcomes typically uses BMI (pre-pregnancy, first prenatal appointment weight or weight at time of delivery) as a primary indicator for study group categorization.

Not only do studies use BMI to include or exclude study participants, but reports have recently emerged that some medical practices are also using BMI as a screening tool: for either accepting or rejecting patients altogether.

The Baltimore Sun recently reported on a slowly emerging trend in southern Florida, in which some maternity care practices are turning away potential new patients, if they weigh more than, say, 200 pounds.  Other doctors practicing in the same area admonish their colleagues for maintaining such policies, despite the increased risk for pregnancy, labor and birth complications many in the industry believe to be an inherent part of attending pregnant women of size.

Other obstetricians, like Dr. Cynthia Maxwell at the University of Toronto Department of Obstetrics & Gynecology, are implementing clinical changes with the aim to improve treatment of and outcomes for overweight expectant mothers, as outlined in this SOCG clinical practice guideline (for which Dr. Maxwell was a principal author).

What the Evidence Shows:  Risks Associated with Maternal Obesity
The basis for heightened concern—whether fueling the exclusion of certain women from their practices, or adopting new approaches to their patient care in response to the growing obesity epidemic—is in the list of complications that are known to coexist with maternal overweight, obesity and morbid obesity.  It should be noted that these weight categories are not all equivalent, and that many of the risk factors we will cover here, and in subsequent posts, become riskier the more overweight or obese an expectant woman is.

In Dr. Tahir Mahmood’s article, Review:  Obesity and pregnancy: an obstetrician’s viewa compilation of statistics from twenty different papers on the subject (British Journal of Diabetes and Vascular Disease 2009; 9: 19-22)—Table 1 provides a an overview of some of the problematic conditions that can be associated with pregnancy in the overweight and obese population:



Other concerns, not listed in this table, but discussed elsewhere in Mahmood’s aricle, as well as in other recent literature include:

-gestational Diabetes (GD)
-thromboembolism
-fetal macrosomia  (birth weight >4,000g)
-difficulty fighting postpartum infections
-maintained overweight/obesity between pregnancies
-prolongation of pregnancy/increased likelihood to deliver postdates
-other short and long term impacts on fetus/infant/child (neural tubes defects, lifetime increased risk of diabetes and obesity…)
-increased risk of stillbirth
-increased risk of maternal mortality
-postpartum hemorrhage

Complicating this issue beyond the fear factor of increasing a woman’s risk of, say, postpartum hemorrhage or fetal loss…is the fact that statistically, the morbidities associated with maternal weight are less than a slam dunk.  While many women of size will go on to develop one or more of the above-listed complications, some of these women will go on to experience completely normal pregnancies, labors and births. At the same time,  some normal–or underweight–women will go on to develop significant morbidities not typically associated with women boasting BMIs less than 25.

For the professionals working with these women during (or, hopefully, before) their pregnancies, the challenge becomes finding a way to communicate the gravity of these possibilities, without assuming every overweight expectant mother is a ticking time bomb—and all the while treating all expectant mothers with the best evidence-based care, no matter what their size.

[In tomorrow’s installment of this series, we will look at some of the particular co-morbidities associated with maternal overweight/obesity, and the types of provider interactions and interventions that evidence does–and does not–support.]


Posted by:  Kimmelin Hull, PA, LCCE

Maternal Obesity, Uncategorized , , , , ,