Fighting Fat Bias and and the Fear of Faulty Cervixes
Tuesday, October 27, 2009 at 6:49PMA birth story titled “A Curvy Gal’s fight for a Natural Childbirth” was posted on My Best Birth by a woman named Jenne who had something of a conflict with her midwife after refusing an unnecessary induction.
Jenne was curious about her midwife’s recommendation that she get a “Miso” induction.
I was scheduled to get induced initially two days before my due date, but thankfully, I rescheduled. I made this induction appointment after a midwife (one of many at my OB practice) told me that going beyond my due date might put my baby at higher risk of stillbirth. The literature does point to pregnancies that go beyond the 42 week mark as being at higher risk, but I wasn’t even at 41 weeks yet. Of course if a medical professional says, “if you don’t do what I am saying, you may hurt your baby”, you listen. She explained my options: I could have a mechanically induced labor to ripen the cervix (“but who wants to have a catheter inside them?” she added) or I could have a “Miso” induction—which she presented as if it were as harmless as having a cup of Miso soup — “you come into the hospital, we give you a small dose of medicine to ripen the cervix overnight, and you’ll probably sleep through it and go into labor the next morning”.
The midwife was talking about Misoprostol, or Cytotec. Jenne researched the risks of the drug and had questions for her midwife.
So how could she justify scheduling me for an induction that posed so many risks for myself and my baby? This midwife clearly did not believe in my body’s ability to birth. She probably assumed I would have a failed induction and need a cesarean. After some research, I called my midwife to say that I did not want a Miso induction, and that I wanted to wait and go into labor spontaneously.
Her midwife responded with some that sounds like it belongs on My OB Said What?!?
“Well, in my experience, women with BMIs higher that 26 tend to have cervixes that won’t dilate without chemical induction.”
Jenne was concerned. Not only is the Body Mass Index badly flawed, in part because no distinction is made between body weight from muscle and body weight from fat which labels a broad segment of the athletic and similar healthy populations as overweight and obese, but because the idea that a hypothetical 5’ 7” woman weighing 168 pounds (a BMI of 26) would be hopeless in labor without chemical induction is ludicrous. View the BMI Project for a reality check.
Okay—first I was being pressured into induction because of the increased risks of a long gestation to my baby and NOW she’s saying that because I am a curvier gal, my body is somehow clueless about giving birth (by the way, I had NO other risk factors in this pregnancy—no gestational diabetes, no elevated blood pressure, etc) I have since searched high and low for ANY medical study that supports her belief and have come up with nothing. I argued with her that I’d like to give my body the chance to go into labor on its own—at least through the weekend (agreeing to the postponed induction with the foley catheter instead). She was condescending and doubtful, but ultimately said it was up to me.
Jenne noted in the comments that it also “seemed like [the midwife] had a personal prejudice against larger women. I later heard that she referred to patients who had gained too much weight during pregnancy as her “walking wounded”.
In order to gather as much information as she could about actual risks and benefits of induction, Jenne contacted Henci Goer, who hosts the Ask Henci forum on the Lamaze International web site.
I wrote an email to Henci Goer, author of wonderful book The Thinking Woman’s Guide to a Better Birth in hopes for some insight. Henci was so encouraging about my body knowing exactly how to birth. She also sent me links to research about induction—particularly the dangers of Cytotec. Luckily, I also had the support of my wonderful doula, Rachel, who encouraged me to wait it out—reminding me that most first time moms average a gestation of 41 weeks and a day. The day I went into labor naturally marked that average—I was pregnant 41 weeks and a day when I had my baby!
Jenne went into labor spontaneously, labored at home for as long as possible and had a wonderful hospital birth experience.
I went to the hospital at 2:00 pm and my 7lb 9oz son, Nathaniel Hayden Lima, was placed in my arms just two and a half hours later. This birth was the most incredible experience of my life so far. I was truly blessed with a beautiful and merciful birth.
Reader Comments (34)
Thank you so much for posting this. As a fat woman, my body is seen as broken and wrong already, and this absolutely translates into birth. I purposely searched for providers who were fat positive, and found some, but heard some pretty obnoixous stuff along the way. My first birth was vaginal but with interventions, and one of the midwives who checked on me afterwards told me that I would have to lose weight or have a smaller baby (first was 8lb7oz) if I ever wanted an uncomplicated birth. Well, I guess I showed her, my second baby was a totally natural home birth of a 9lb5ozer! Fat women get told they are not good enough for pretty much anything, it's nice to hear that acknowledged.
BMI is a complete crock, so I haven't checked it in years. Until thought it would be amusing to for this comment. Apparently, I should be dead or something, instead of the reasonably healthy mother of an 8 year old, 4 year old & 7 month old. The last 2 who came in completely spontaneous, vaginal births at about 37 weeks & at 40w5d. Active labour for the baby was about 4 1/2 hours. The fatphobia, blaming & *lies* about the dangers of being fat need to end!
Well-rounded mama has a great blog about birth & about obesity bias.
(the BMI was 44.1, btw, that medwife would've freaked)
I've been thinking a lot about this sort of thing lately and I'm really glad you posted this. It's hard enough to find an unbiased, fat-friendly, knowledgeable health care provide, let alone trying to accomplish that while pregnant.
Her example is funny, since I *am* 5'7" and average between 165 & 170lb. All my babies were born naturally at home - first labor was 5 hours, second was 4 hours, third was around 2-1/2 hours. I guess no one told my cervix that it was incapable of dilating without mechanical assistance!!
Oh, and I have to agree about the silliness of BMI. I started running before my third pregnancy. Although I dropped a good amount of fat - my body hardened significantly and I went down 2 pants sizes - my weight, and thus my BMI, stayed the same. What I had done was drop a significant amount of fat and replaced it with heavier, stronger, denser muscle tissue.
Welllll, from a super-sized midwife who had 3 kids as a super-sized woman, I am here to speak on behalf of the fat women who *do* need help to birth their children. Women who have PCOS not only have a hard time getting pregnant, they often have a hard time getting *un*pregnant. There is a very real biochemical misfire that affects the hormones surrounding birth. The main "fertility" medication is Glucophage/Metformin... the medication used for PCOS/Insulin Resistance.
BMI is very outdated and, besides, each woman has her own set-point for when issues arise. For me, I stop having periods at 280 pounds, but they aren't regular again until I am about 220. For other women, they ovulate perfectly normally until they weigh 375... and still others stop ovulating about 230. It isn't an exact science, so that nurse was ridiculous in what she was saying - it was pretty obvious her fat phobia.
Please know that fat women CAN have issues, even those that test "negative" for GDM. Women don't get fat by eating 1500 calories a day. It is denial to think otherwise. Fat women walk the line between health and Insulin Resistance/PCOS/GDM and the line blurs the fatter a woman is. Working on the diet isn't a bad thing for fat pregnant women. I think it's easier sometimes for me, a very fat woman, to look another fat woman in the eye and say, "Let's work on this together." It's easier for some women to talk to me about their food choices/issues - and I don't mince words when talking about the whole food thing.
Believing that all fat women are perfectly fine is just as bad as thinking that all women left alone won't need a cesarean; it's unrealistic and untrue.
Let's meet each other where the truth is and then birth can unfold exactly how it should.
NGM - all that may be true, but you're painting a canvas with a makeup brush with that statement. The number of women who will fit that bill AND have those problems you've described is not as common as your note would lead readers to believe. Nor is it exclusive to overweight mothers. Many skinny women suffer with PCOS. While obesity is a symptom, it isn't a requirement. You're far more likely to see a skinny woman with PCOS than a woman who truly *can't* and *never will* go into labour, even at 45 weeks with an otherwise healthy pregnancy.
In these cases you speak of, how long did you "allow" your clients to wait before "agreeing" to an induction or cesarean? Were there any other indications that the pregnancy, or baby, were irregular? Pre-existing endocrine disorders? Thyroid problems? There are so many variables in what you're describing that it would seem impossible to truly blame one cause or another.
The other part that bothers me is the lack of citations. Your note seems largely anecdotal - and tone rather argumentative. Unless there's some research on this topic from women who have gone *significantly overdue without "help"* and they have linked the cause directly to a lack of ability to produce oxytocin, even under stimulation (ie, nipples, sexual activity... even in bursts)... I'm skeptical there are enough cases of this to make it worth mentioning.
For the record, in the worst times of my suffering with PCOS I was never more than a BMI of nineteen. I also have a notable hormone disorder that caused a halt in all my growth and maturation at age eight. I underwent treatment at 14, but growth was irregular and damaged. Hormone problems remained: I never "produced" correctly. Despite a constant slew of fertility and hormone problems (including menopause before my 30's) somehow I went on to have three totally normal pregnancies and births: 40.5 weeks, 34 weeks and 43 weeks.
My labours were 44 hours, 2.5 hours and 3 hours - and all very normal. :)
Of course, this is all anecdotal and not really worth a damn... but it's worth putting out there.
Much like those women who truly cannot breastfeed, even a little (it happens, but it's exceedingly rare!), why should we treat the masses with the extreme caution that really needs to be awarded to a fraction of cases...? To those of which have obvious indications without excessive risk? I'd say someone with a history of diagnosed PCOS reaching 44 weeks without a single release of oxytocin for even a set of braxton hicks contractions is a good candidate for consideration. ;)
...But a fat woman at 42 weeks? We all know better than to paint the 100% with the .00001% brush!
NGM, the fact that you consider 280 to be "supersized" says it all. Fatphobia is often the worst from fat women. Most fat women do not have insulin resistance/PCOS, and I would love for you to find a single source that says otherwise. Please check your internalized hatred before spewing it on the rest of us.
Good for Jenne. Educating yourself and then standing up for yourself is the most important thing a woman can do in giving birth. Basing the liklihood of spontaneous labor on BMI is ridiculous. I don't know what my BMI is, but I'm 5'4" and weigh 240 not pregnant (got up to 263 while pregnant). And even though my baby was not in an optimal position (head centered and pushing on cervix) I still went into labor spontaneously and dialated fully.
Great post, Jill, about an incredibly triumphant birth story.
I also read this story from the BBC yesterday about the U.S. maternal mortality rate being a "scandal" (which it is) - and citing the increased risk among obese women as well as the overuse of cesarean. Regardless of the debate about which women are obese and unhealthy and which are obese (by BMI) and healthy, I think this all underscores the need to be even *more* cautious about our use of interventions and cesarean surgery in high-weight women. If obese women are more at risk for complications of cesarean (including death), we should do everything in our power to safely prevent cesarean. That includes *not* inducing women for bogus reasons, undermining their confidence in their bodies, and using unsafe medications when safer alternatives exist.
At the risk of being yelled at (wow, Kristin, easy there...) I just wanted to note that obesity has been found in numerous studies to be associated with an increased risk of postdates pregnancy (>42weeks). Obesity is an established risk factor for postdates pregnancy. Further caucasian and pacific islander race is also associated with an increased risk of postdates, while asian and black women are less likely to be effected by postdates. At last weeks MANA conference an interesting theory was voiced (as yet unstudied) about obseity and it's relationship with postdates pregnancy; that the extra endogenous estrogen secreted by adipose may interfere with the cascade of hormonal triggers for spontaneous labor.
I agree that the midwife in this story clearly had issues with this woman's size, and also agree that her approach was horrendous. I'm coming down on the side of cytotec/miso induction being much riskier than expectant management of an overweight client. I don't think this represents midwifery care *at all*. I'd point out that at 41 and 1 day when she actually *had her baby* she wasn't postdates... But we can argue about the arbitrary 42 week number till the cows come home...
Morag - that's immediately flawed. Blacks have the highest rate of obesity...
http://www.cdc.gov/obesity/downloads/obesity_trends_2008.pdf
Also, postdates =/= never going into labour, and I don't immediately see the relevance of comparing them. There are so many socioeconomic variables.
Hi Kristin,
I need to ask you to please stay respectful of other commenters. A line like "Please check your internalized hatred before spewing it on the rest of us" is too harsh.
Thank you,
Jill
Navelgazing Midwife said: "Believing that all fat women are perfectly fine is just as bad as thinking that all women left alone won't need a cesarean; it's unrealistic and untrue.
Let's meet each other where the truth is and then birth can unfold exactly how it should."
Did something in this post sound disingenous or dishonest? Could you please point me to whatever it was that sounded like "all fat women are perfectly fine?" Or did the post just spark some thoughts?
You're right. Anecdotal all the way. And talking to docs and midwives over the last 27 years, but if it isn't in the literature, it doesn't exist, right?
I was not trying to be argumentative at all. And that I am fat prejudiced is a hoot. I have long been a fat-friendly healthcare provider, making room in my practice to always accomodate fat women... from chairs without arms to the right sized speculums sometimes needed for pelvic exams. But, defending myself is not terribly important... not as important as living the life I know to be true to ALL women, fat or not.
Fat is a hot-button issue and women, myself included, kick back to defend themselves. For at least 30 years, I said things like, "But, I'm a vegan!" "I come from hearty stock," or "I don't know why I'm so fat." The reality is if we all lived the lives of migrating people, NONE of us would be fat. It is those that sit idle and eat more calories than we burn that get fat.
And being fat can -and does- affect SOME pregnancies... depending on how fat the woman is and how well she treats herself and her pregnancy. To discount that is sticking your head in the sand.
280 *is* super-sized. One a 5' tall woman it is. On a 6' woman, it wouldn't be, but how many of us are 6' tall? super-sized is when you are no longer buying clothes in stores, but are buying them out of catalogues or on-line. I am on the cusp of super-sized again. And I weigh more than 280. (Not bragging; it irks me.)
I would hope that *I* was heard as much as all the rest of you. Not just because I am fat or a midwife, but because I have a valid voice, too.
So many things to comment about on this!
First, thanks for posting her story. The rate of induction of women of size is incredibly high, and while some of it is because of a higher rate of complications like GD or PE, often it's because of suspected macrosomia (which actually increases the risk for CS, on average, rather than lowering the risk) or for postdates (women of size do have a higher rate of postdates pregnancy, but we also have higher rates of longer cycles, which often are NOT adjusted for in due dates) or simply because many care providers do not believe that fat women's bodies work when left alone or that they are strong enough or fit enough to have a healthy pregnancy or birth.
The fact is that many of us DO have healthy pregnancies and births, with or without PCOS. Yes, there are some who don't, and I think the metabolic abnormalities of PCOS have a big role in that, and of course there ARE some fat people who really do have messed-up eating habits and/or eating disorders. "Obesity" is a complex issue, one without simplistic answers and generalizations, which i s one of the messages I always try to get across, but one which so many people resist.
NGM, I honor the work that you have done over the years for many women, including women of size. We have met in person and there are many things I admire about you.
However, we will have to agree to disagree about all fat people having bad eating habits and eating disorders. I thnk your own experiences...and the denial of your own binge eating and issues....have colored your views so that you generalize them to all fat people. We all must be lying about our intakes because you were. (I say that with loving intentions, not critical ones, although you may not hear it that way.) What I hear you saying is that we all must be in denial about our habits and that's why we're really fat.
I say that there ARE certainly some fat folk who are in denial, and some who truly have eating disorders. I also assert that there are plenty who do not. I agree with you that pretending that all fat women have healthy pregnancies and no issues is a disservice....but over-characterizing the risks the way the media does is a tremendous disservice too. I completely agree that proactive behavior....good sensible eating and exercise...can go a long way towards mitigating risk....but it's not all about being proactive either, because PCOS can and does do a number too. Sometimes intervention is needed in the pregnancies of women of size, but often, our pregnancies do perfectly fine with a tincture of patience and belief.
I have to run and get my kids from school and can't take time to reread and vet this, so I hope this makes sense and doesn't come across as rude. I don't mean it that way. I just want to make the point that there is more than one truth out there, and that one person's truth doesn't make it true for everyone else. Also that being an outlier statistically (either in weight or length of pregnancy etc.) doesn't necessarily make it abnormal or pathological or harmful.
There is a wide spectrum of experiences in plus-size-pregnancy, from the unhealthy to the completely healthy to everything in between. Not portraying that spectrum accurately is part of what's wrong with media coverage of obesity and pregnancy these days, IMO.
-kmom
www.plus-size-pregnancy.org
www.wellroundedmama.blogspot.com
I was dx'd with PCOS by an RE before I got pregnant with my daughter - went on Met, got pregnant and stayed on it through the first few weeks (worst m/s I've ever had in all three pregnancies, could barely get out of bed) before going off it (when the m/s completely disappeared). Switched to a midwife, had a very uneventful pregnancy, and went into labor at 40+3 - my very first vaginal birth and my body's very first chance at going into labor since the first was a "primary c/s for suspected fetal macrosomia" because I didn't go into labor on my own by 39 weeks. Very easy labor/birth. Gosh was it ever hard for me to "get un-pregnant"! Oh and I was fat to boot (which is probably the only reason I was sectioned with ds - should have seen the red flags there).
I typically love the kinds of things you post, NG, but am I ever glad my midwife has a different perspective on things. You are right, you do have a right to be heard. Thank you for a good reminder to always interview your care provider carefully. One person's dream provider is a poor fit for another.
WRM had a very good post along these lines this week.
Oh and I should have added that the third pregnancy is progressing the same as the other two - Uneventful. As for the PCOS and difficulties getting pregnant thing...that didn't pan out this time as this one was very much an "oops!"
Context and individuality really do need to be king in this issue - assumptions on either part do more harm than good.
Absolutely on the interview front. The consult goes both ways. One midwife's delightful client is another's nightmare. TRUST is an absolute must in the midwifery/client relationship (and it IS a relationship). It is a great thing to know and admit you would or would not be a good fit. This issue is but one of an endless list of topics that can/should be brought up by both the mother and the midwife. I tell women to pick the midwife they would feel comfortable with in a small room for 20 hours; if she annoys you with her quirks in the consult, she will drive you bonkers in labor. And, fwiw, it is not too late to change providers, even near the end of the pregnancy. Your pregnancy, labor and birth are too important to worry about the midwife's feelings. A mature midwife wants her clients (and consults) to find the exact right midwife for them.
KMom: I think what you and I are saying is pretty similar. Usually in these issues, we are pretty aligned. I don't think this is much different. (And you know how I admire you, I hope.)
I will take a second to say that when you say, "and the denial of your own binge eating and issues" would REALLY piss me off if I wanted to take offense at this. Rather presumptive to diagnose my eating issues, isn't it? This type of statement is extremely inflammatory and I would ask that I not be therapized when having a cogent discussion.
But, fwiw, I absolutely acknowledge my compulsive eating issues (my disorder is not binge eating) and fight with them continually. It saddens me that I have so little control over my own eating that I needed surgical portion control - and STILL managed to eat through that over the last 8 years. If someone wants to ASK what my issue might be, then ask. Please don't diagnose me without living with me, being my therapist or being a part of my life where you have been invited in. I admit my issue, but I am hardly proud.
Sorry, NGM, if my phrasing was off. As I said, I was rushing through my reply.
However, you've been pretty frank about your eating issues on your blogs. Seemed to me like you had said before you were a binge eater but I didn't go back to double-check if that was the phrase you used. if you are drawing a finer distinction between compulsive eating and binge eating, okay. They seem similar to me but not being in the eating disorder community, I may not be aware of the correct definitions.
I wouldn't normally make presumptions about someone else's eating, but as I've said, you've been very upfront about your own challenges on your blog and elsewhere, whatever the correct label is.
I just ask that you don't make presumptions about mine or anyone else's, just because of size. I acknowledge your truth is your truth, but your truth is not universal to all fat folk.
I prefer to keep in mind our commonalities rather than our differences, because in many ways we want similar things. Let's keep concentrating on those.