Do Overweight Pregnant Women Need Separate High-Risk Hospitals?
Thursday, June 10, 2010 at 8:42AM
By ANaturalAdvocate
This past Saturday, The New York Times published an article titled “Growing Obesity Increases Perils of Childbearing.” Moving right past the fact that the “perils of childbirth” are assumed, Hartocollis writes about the rising level of obesity and how this has affected obstetrics in the US. To illustrate the point, Hartocollis references the measures hospitals have had to take in order to account for this “burden in the maternity ward” and describes a premature birth (by Caesarean section) of a boy born to a mother who was estimated to be very obese when she became pregnant (either morbidly or extremely so, depending on whose terminology you use).
Ms. Garcia, the mother profiled by Hartocollis, had a BMI of 38 at the start of pregnancy and delivered her son 11 weeks premature after suffering from a number of complications described as “a constellation of illnesses related to her weight.” The chair of obstetrics of Maimonides, where Ms. Garcia delivered, is quoting as saying that doctors must weigh the risks of sections against the risks of vaginal deliveries in obese women. Maimonides is one of five hospitals in the New York City area now working together - with their malpractice insurer and a research group - to help figure out “the problem” of obesity during pregnancy. According to Dr. Adam Buckley of Beth Israel Hospital North, another center in the group, one solution might be to form hospitals designed specifically to handle obese women.
“The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean sections and intensive care for newborns,” Dr. Buckley is quoted in the article. These specialized centers would, presumably, solve some of the issues discussed in the article, such as obtaining sturdier examining tables and equipment and purchasing more precise fetal monitoring and diagnostic equipment. They would also have staff better trained to deal with variances in human anatomy, such as more adipose tissue that sometimes requires a different technique in procedures and anesthesia. At least one hospital in England has taken to this idea, requiring that women with BMIs of over 34 seek care approximately 20 miles away, in a better staffed maternity facility.
Hartocollis describes the sadness that Ms. Garcia felt, seeing her baby boy, born at less than 2 pounds, living in the NICU. She promises that she will go on a “strict, strict, strict diet,” promising her doctor that she will see her son graduate from college. While Ms. Garcia clearly has health problems to overcome - having suffered from kidney ailments and a stroke while pregnant - I am not convinced that specialized centers will solve “the obesity problem” in pregnancy, or even that the problem is even such as described.
To begin with, in the US obesity is described by BMI, or body-mass index. The equation used to determine BMI is:
BMI = [ (weight in pounds) / (height in inches)2 ] x 703.
Note that this equation *only* uses height and weight, period. There is no measurement for body fat, build, or athletic activity. As such, BMI is considered by many to be an inaccurate, at best, measurement of actual health. The Centers for Disease Control and Prevention states that BMI is not a diagnostic tool and that other measurements should be used to indicate health; BMI is simply a “screening tool.” The CDC also says that BMI measurements can vary in accuracy depending on age, race, and sex, and that measurements can be off for those more engaged in athletic activity, whose composition will likely be less fat and more muscle. An article recently published by the American College of Obstetricians and Gynecologists (ACOG) indicated that BMI measurements were also not as accurate as might be hoped in identifying obese women for counseling and risk purposes, although the article indicated that BMI missed more women than falsely included. The World Health Organization uses body fat measurements over BMI as a better indicator of health, preferring the precision and individuality of that measurement. However, body fat measurement requires more than merely a scale, tape measure, and calculator. Instead, body fat measurement requires calipers (and a well-trained provider), an immersion pool, or other inconvenient methods. Clearly, however, the measurements behind this push for specialized obese pregnancy centers are flawed in themselves, bringing into question the classifications for the higher risk and care.
Even assuming that the measurements for obesity are accurate, the question remains as to whether obese women - properly classified as such - need specialized care based on obesity alone. While obese women are at a higher risk for some complications of pregnancy, including hypertension, gestational diabetes, and pre-eclampsia, not all obese women will have these complications - and many “normal” or “overweight” woman will. If these centers become realities, will women be shuffled into them based merely on their BMI, or will some actual risk or complication have to become apparent before restricting places of birth? Already women describe being told in the first trimester that they will require a section, or that lower incisions don’t matter because clearly a larger woman does not care about her appearance and scarring, or that she is guaranteed to have gestational diabetes and a baby too large and unhealthy. These experiences, and the idea of specialized care centers based solely on a woman’s weight (without regard to actual risk and complications) are related more to size-phobia than to true care. Unfortunately, many people, including physicians, feel that women who are overweight or obese are lazy, do not care about their health, and “deserve” any complications coming to them. This is not a matter of needing specialized care in a segregated hospital, but needing providers who are aware of the potential special needs of an obese mother (or any mother), and who are not judgmental. All pregnant women should maintain an appropriate diet and level of activity, regardless of their BMI. Size-phobia, and related discrimination, can lead to poor care, assumptions, unnecessary interventions, and a C-section just as quickly as age- or race-related discrimination in obstetrics.
Finally, given the current crisis in maternity care in the US, what is the likelihood that these specialized centers or physicians will even offer the midwifery model of care, instead relying on frequent monitoring and additional testing (the cons of which are discussed on this blog and many others)? Given that counseling and support are recommended over diets, pills, and surgeries for encouraging healthy weight, how likely is it that women will receive such counseling and support when many OBs limit visits to fewer than 20 minutes? Will the classification of “obesity” require a specialist and yet more visits to health care providers during pregnancy? Will these specialized care centers also be equipped with a variety of less visible changes, such as blood pressure cuffs in various sizes, anesthesiologists capable of performing epidurals on women with more adipose tissue, and waiting room chairs designed for larger frames? Or will they simply be equipped with sturdier, and more plentiful, operating tables?
For more information on size and pregnancy, I highly recommend The Well-Rounded Mama (who just posted about this article as well).
For information on size issues generally, I highly recommend Shapely Prose.
Reader Comments (26)
Thank you! I'm glad to see such a positive and well-researched article on this topic. I was sorely disappointed by another blog's recent post on this issue and am glad that this one isn't fat-phobic and women-blaming.
I have to agree with you that it is ALL size-phobia. When I got pregnant, I was 19, on state-insurance, and 300 lbs (at 5'10). I knew that if I went to an OB, I'd likely be told I needed a section based solely on my size and nothing more. So I searched for a midwife. I found what I thought was a lovely midwife, and she told me she'd take my care as long as I didn't develop problems. I followed the blue-ribbon baby diet, which was a real departure from how I'd eaten before, and refused all glucose-tolerance tests. I knew that because I have insulin resistance already, that to give me a overly-sugary drink would result in a false positive and I'd lose my chance at a birth center birth. I created my own plan, where I saw a nutritional counselor once a week with a food log, and tested my blood sugar 5 times a day with a glucose monitor. I did this for 7 weeks. The nutritional counselor even commented that she'd never seen blood sugars as absolutely perfect as mine. I had one high reading, but that was from superbowl, and I was a pregnant woman surrounded by lots of yummy food, so it didn't count...
By 30 weeks, I was starting to get perturbed at my midwife. She'd hardly touch my stomach at all to find the baby. She'd only put her monitor on the top part of my abdomen, near my ribcage. And then she'd remark about how she couldn't find the heartbeat. I'd be telling her, "She's down here. She's over here." and she'd not listen to me. At my next appointment, my blood pressure was high, and she immediately started talking about moving me to an OB. My blood pressure was high because I'd just been with my Mother-in-law who was having chemotherapy, and a bone-marrow withdrawal. I don't know a single person that wouldn't have had high pressures in that environment!
At 36 weeks, she dropped the bomb. She said that she didn't feel comfortable being my midwife, that her doppler had a hard time picking up the baby's heart and she thought I'd have a better delivery with a midwife/OB team at the local teaching hospital. I thought I would just fall over. I spent a week beside myself with guilt for gaining too much weight (I never stepped on a scale, but I think I gained 30 lbs), for not doing the GTT, for being too big.
Finally, a midwife friend across the country convinced me to find new care. I did find a great midwife team in a free-standing birth center, and my birth was back on track. As I interviewed midwives, several of them told me that they thought my first midwife was waiting for me to risk myself out of a midwife-birth, which is why she so readily jumped on me for the blood pressure.
Labor started when my waters broke, and contractions never picked up unless I walked around, and would peter out immediately everytime I stopped. Together, we decided a hospital transfer was what was best for me, as I was exhausted after 30 hours. Upon transferring, I got to experience the joys of a hospital birth, from the obese perspective. First of all, of the 7 hospitals in an hour radius, none of them would take an obese woman with ruptured waters past 24 hours. They all claimed they had no beds, and even if they did, they were too small. My midwife finally called in a favor to the lead perinatologist at one of the hospitals.
When we arrived, they immediately said c-section. I said, "pitocin and an epidural". They called the anesthesiologist, and when he came in, his face scrunched up into this ugly sneer that he should have to touch me. The doctors were the same way, And it wasn't just my perception, as my mother, the student midwife, and my husband all saw the same thing. They berated me to have a c-section the moment I walked in. At one point, when I'd been there about 7 hours, a doctor came in, lifted the sheets, checked me roughly without even introducing himself to my family or more importantly, me, and announced that I had two hours to complete from 7 cm or...well, no worries, he was booking the OR then.
This is when my blood pressure spiked and the baby started looking distressed on the monitors. I told my husband to put on some mellow music and I meditated for myself and the baby, and our numbers went back to normal. I was completely dialated after just an hour and 45 minutes, beating that stupid OR-happy doc, and pushed the baby out in two hours, which was a small wonder as the doctor kept trying to look away from my yoni.
My experiences proved to me that there is a pervasive fat-phobia in our culture. Seperating fat women into a "specialised" hospital is a sick idea to me. The women most at risk for health issues, maybe, but with the right nutritional counseling, and a gentle, encouraging voice, and maybe some supportive group exercise would help most at-risk Obese mommas towards a healthy pregnancy and labor. And not every obese woman is at-risk.
I would love to see more obese women encouraged to have vaginal deliveries, not only for the intrinsic value of such delivery, but also because the surgical risks (e.g. C-section) can be magnified by excess weight. And, of course, not all overweight and obese women are going to have pregnancy-related problems.
Holly--what a very interesting and awful story! I can't believe that....no, scratch that....I CAN believe that doctors would treat you with such disrespect. I so wish things were different. How dreadful!
And with regards to BMI, my dear husband is considered overweight at 200 pounds and 6 feet tall. All BMI indicators say he's "overweight," but he is very athletic and in fantastic shape. Since he has more muscle mass than most people his size, the BMI is wildly inaccurate for him. His body fat is something like 4%. I've never understood the rationale for using the BMI....seems kind of like junk science to me and it's infuriating (though not surprising) that they are using it as a decision-making factor in who gets forced into additional prenatal "care" and c-sections. BLAH.
Yeah, really, KK! You would think that if overweight or obese moms are at higher risk for issues with surgical intervention that they would try to help them avoid a c-section, not coerce them into one!
I second what Morgan said. Thank you.
Right now I am considered obese by BMI standards. When I first found out I was pregnant a few weeks ago it really bothered me. I have to admit I couldn't help but wonder if I was truly at risk for some horrible things..if it would affect my chose to homebirth, etc. It was all fear, with little fact or evidence. When I tell people I am considered obese that don't believe it..I am 6'1 tall and 228lbs at the beginning of my pregnancy. My usual weight is 177..so I am significantly over weight by my usual standards..but the funny thing is at 177lbs I look so much thinner.
Like everything, there's balance to be had. I definitely don't think that building more OR's is the solution- obese women like every woman should be encouraged to deliver in the safest way possible. However, as someone who has struggled with weight issues I also feel that women need to take responsibility for their health, especially when they're pregnant, and do everything they can to keep from gaining too much weight and developing weight-related pregnancy issues. Obviously some things are out of our control, but it just makes sense to eat well and exercise if possible for anyone during pregnancy, and especially for those who are deemed obese by any measurement, BMI included. I surely don't like the BMI much (I've always been outside the normal range for my height), but the article wasn't talking about people who are just measuring "overweight", but obese or worse.
I guess my general conclusion is that women who are pregnant and obese need even better, evidence-based one-on-one care than a woman in the more normal range. They need more support and encouragement, and less people telling them that they will need a c-section. Many women in that situation are already insecure, and what they hear from OB's and even some midwives about their inability to give birth may likely lead to some of the problems with the birth process itself.
Holly: I am sorry that you had to deal with a number of care providers who simply weren't what they should have been. I'm glad that you were able to show them wrong!
KK: So true, and not a point I'd thought of while writing this.
Augusta: Part of my concern with this whole setup is that the US tends to use BMI to diagnose obesity, rather than taking a number of factors into account. Body fat, as some places use, would be a much better single number to use but, as I mention, it's less convenient (and especially so if using one of the most accurate methods of determination, as calipers in untrained hands can come up with some funny results too).
Sara: Clearly we are responsible for our own health, but sometimes it's a little more difficult to be responsible for it than in other situations. For instance, in my family women come in Large, period. I used to joke with friends that if I was more vertical than horizontal, I was winning the battle; it was crude, but fairly accurate. However, when I went to a nutritionist and PCP to make sure that I was healthy and eating appropriately (so as not to face the battles prevalent in the rest of my family), I was told that my insurance would not cover the nutritionist at all, or further testing because I was not "bad enough." Mind you, if I was willing to gain ~75 lbs., they would be happy to send me to a bariatric surgeon... Obviously this was not an appropriate answer, and I paid for the nutritionist and additional testing out of pocket. Not all women have the resources to do so, however, meaning that other women (and men) also on my insurance, who are unable to pay out of pocket for these health expenses, may not be able to obtain medical help when desired. Instead, they'll continue to rely on Jenny Craig and Weight Watchers and other "diets," most of which can result in harm after repeated trials - and bounceback weight gain.
In addition, while the article and the "specialized centers" referenced obese women, the question is: are these women really obese? A measurement based solely on height and weight, not taking into account diet or activity or body fat, is not accurately able to determine "true" obesity with the attendant health risks.
I don't think, though, that overweight/obese women need one-on-one support any more (or less) than every other woman. Pregnancy care and support should all be individualized and allow for particular care, whether the need for it is resulting from extra weight, or emotional issues, or eating disorders, or anything else, really. I agree, though, that all women need fewer women telling them they need a section. :)
Honestly, my BMI classifies me as obese. A year ago I gave birth to my son naturally in a hospital attended by a midwife. I have one of the few medical/hormonal conditions that cause weight gain or at least severely prevent weight loss. I exercise at least 45-60 minutes daily and I still have to restrict my calories greatly to even lose a few pounds. Doctors do not understand that type of medical problem. I have been misdiagnosed for most of my life. Since my medical condition also results in insulin resistance, I tested positive for gestational diabetes at 8 weeks pregnant with my son. Fortunately, I am usually quite careful about my diet and exercise anyway so I did not have much to change but even my midwife struggled with the OB that the hospital assigned me as back up since I was "high risk." I had to monitor my blood sugar 5x daily and I had to have multiple ultrasounds to make sure that my baby wasn't getting "too big." Fortunately I was also taking Bradley classes and doing a lot of research on natural birth so I was aware of the ways ultrasounds could be misleading. I also had to fight some pressure for an induction. In my case, I was lucky that the OB refused to listen to my knowledge of when my son was conceived and on the advice of my midwife went with the EDD that the ultrasound gave me which was almost two weeks later. The OB scheduled me for an induction on my due date but I went into labor the night before (at my guess 41.5 weeks gestational age). I am just so thankful that I didn't have an induction. It is infuriating to be treated as high risk, which means "we get to do whatever we want and you have no say about it," just because some non-specific test that doesn't even measure health says so.
Of course, the medical establishment tends to categorize all illnesses as weight-related, so it's hard to sort through the data. Have you been exposed to a workplace toxin? Then convincing doctors (and lawyers and regulatory agencies) that your kidney problems are linked to environmental toxins in going to be very fucking hard for you if your BMI is above one of their artificial little lines. Are you thin? Well then your chances of getting a quick diagnosis and treatment, as well as bringing about some real change in your workplace, are much higher. And every woman I know whose BMI is higher has had issues during pregnancy that were attributed to weight - mostly gestational diabetes. Back in the day, they used to worry about pregnant women being too thin to carry a healthy baby. Now? Not so much.
Separate hospitals &/or policies aren't the way to go. Recognizing that obesity may increase risks and watching for them is more appropriate and will better ensure good care. I was an obese mother the first time i gave birth (and i will be this time, too...). I was physically active (as in step aerobics classes and speed walking up hills and stairs, etc... not just strolling and gardening and other wonderful yet gentle physical activity) every day during pregnancy, ate well, and had a perfectly normal, uncomplicated 'easy' vaginal birth. (I was told my birth was 'easy' compared to 'normal' standards of first time births... i guess i'm glad, 'cause while i didn't suffer from exhaustion, which was my biggest worry, i certainly didn't think it was 'easy'.) My highest BMI rating ever was a 39. I am sure i was lower than that while pregnant, because i was 35 to 45 pounds lighter then than i was at my heaviest. But i was still at least 30 pounds over rating 'non-obese' by the charts. While weight is something to keep in mind, it's still just something to keep in mind. An obese woman can be in better physical health than a non-obese woman; it may be an important factor in health, but it is not the ONLY factor in health. We need to always make decisions based on the INDIVIDUAL PERSON, and not just shove them into a category and follow 'automatic' policies because of one factor or another. (This goes for 'old' mothers, teen mothers, previous c-sec mothers, etc etc etc.)
1. I initially reacted when I read the NY Times article on Saturday because I thought it was a backlash to all of the VBAC and cesarean rate articles that have been published in the last six months or so, particularly in New York. I reread it several times and concluded that the part I was reacting to was merely the author’s use of the typical fat phobic verbiage when talking about any health issues. The headline and first paragraph were a tad over-the-top. Look at the title visible in the top of your browser window: Obese Mothers a Burden on Hospital Resources. Not just obese pregnant women but obese mothers. Come on, now. And an article on health that blames the so-called obesity epidemic? Isn’t that a daily occurrence across the country?
2. Reading on, I realized the heart and point of the article was the work of this new consortium that has been founded. My Google skills are failing me and I can’t find the original press release online. We know that the United Hospital Fund, a philanthropic organization, is funding it along with some unnamed malpractice insurers.
3. If the goal is to accommodate women of size with fat-friendly equipment and beds, then by all means, make it happen, right? How many laboring women (or other patients) are really so large that they’re breaking hospital beds, though? Enough to set up separate bariatric maternity facilities in each city? I need numbers.
4. What sat with me after reading ANaturalAdvocate’s take on it were three things: namely, where midwifery care would fit into this scenario, the fact that thin does not always equal low risk and fat does not always equal high risk and that the BMI appears to be, as Augusta put it, junk science.
5. The big eyeroller for me in the original article was this:
Very obese women, or those with a B.M.I. of 35 or higher, are three to four times as likely to deliver their first baby by Caesarean section as first-time mothers of normal weight, according to a study by the Consortium on Safe Labor of the National Institutes of Health.
Just because “very obese women” GET more cesareans doesn’t mean that they actually REQUIRE more cesareans for a safe delivery. We’ll never really know how much is due to an anchoring bias. If you believe that fat women are risky patients, are you more likely to overtreat to CYA? I wonder about the role of the malpractice insurer in funding this consortium. Insurance companies rely on BMI to quantify fatness and risk.
6. I’m going to withhold judgment about the consortium’s goals until I read more about the consortium directly from the consortium.
ANaturalAdvocate is right. The Well-Rounded Mama covered this well and looked at the (exaggerated) way that women are informed of risk.
great analysis, Jill and ANA. Thanks.
Jill:
Great point on #5, especially. I really feel that size-phobia (both for obese women and "skinny" women) can push a LOT of intervention.
Thanks for blogging about this!! I'm glad I'm not the only voice in the wilderness on this. For those who haven't seen it yet, you can read my blog post about this NYT article at http://wellroundedmama.blogspot.com/2010/06/exaggerating-risks-again.html.
There were many things about the article that bothered me, but the two that stay with me the most are this idea of special care centers for obese women (likely taking away low-tech care choices from fat women) and the quote from the doctor that implied that vaginal delivery in fat women was MORE dangerous than a cesarean for them. AUGH!!!
I have heard from several women or midwives recently that are being told that VBAC is not an option for them because of size, and I know of others who have been dropped by homebirth midwives because of size. What a deeply disturbing trend. Soon our only choices will be to go to the high-risk c-section factories, and I cannot see that improving outcomes when surgery carries more risks in us anyhow.
I am so very troubled by the idea of fat women being pushed into high-intervention care because of the exaggerated fears around pregnancy in women of size, yet I see this more and more as the coming trend. I think it portends very bad things for women of size, and I hope that the doctors, midwives, and other birth professionals who read this blog will continue to advocate for equal access to low-tech care for women of size whenever appropriate.
Fat women CAN give birth vaginally, but rarely are they given a decent chance to anymore. We must push back for equal access to decent, sensitive, and SIZE-FRIENDLY care.
Ridiculous. Any other surgery and doctors will wait as long as possible so a patient can lose weight before the surgery. Why? Because surgery is more risky in overweight patients. Why OB's seem to think surgery is safer than vaginal birth in an overweight woman is beyond me.
The hospital where I gave birth currently has a 48% C-section rate. My mother works in this hospital and says that they routinely section all of the obese women. I'm not sure many of them even get to labor, it's basically straight to the OR. I have a friend who is obese and had a baby there and they sectioned her. If a "special" hospital is created for obese women in NYC, they are doomed. That hospital's C-section rate will be near 100%. I can't imagine it going any other way. Cecily from Uppercase Woman blogged about her experiences with pregnancy as an obese woman and I think it's a must-read! http://www.uppercasewoman.com/wastedbirthcontrol/2010/06/obesity-pregnancy-and-the-new-york-times.html
I've been watching these articles and discussions closely since I technically qualify as obese and delivered my daughter at home easily last October. I'm also an OB RN and had a patient situation recently that burned me up regarding a very large woman who delivered nearly precipitously (although the MDs were calling it a "soft tissue dystocia") because no one believed her. I hear comments made all the time about how fat women "can't push babies out anyway" so why even bother with a trial of labor. One of the many reasons I chose to deliver at home, even though in general, I think my hospital is relatively evidence based in most things.
Jill - Thanks for doing all this research about this topic. I really don't think separate hospitals sound like the answer. What I was thinking about was that, as I just learned in school the other day (I'm a nursing student), they are going away from the term "culturally competent care" toward "cultural humility" because we don't assume everyone from the same culture has the same health needs.
Could that be extended toward obesity? While, yes, there are certain health conditions that increase with obesity, this does not mean that pregnant women in the same weight class will all have the same risk factors. Women over a certain BMI do not all need the same care; they are each an individual patient. Weight and fat composition should be considered one factor in the broader picture of health.