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.
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.