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Sunday
Aug222010

Comment of the Week: Obesity is the Perfect Scapegoat

 

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By Jill—Unnecesarean

This comment was left by the Well-Rounded Mama on the post Obesity Causes a Rise in… Articles about the Cesarean Rate.

 

One of the things these articles rarely note is that “obese” women are induced at mind-bogglingly high rates, usually for “suspected macrosomia” or for “postdates” but sometimes also just because the docs believe that fat women don’t go into labor on their own or are too high-risk to contemplate going longer.

We know from other research that induction STRONGLY raises the risk for cesarean, especially in first-time moms, in moms with suspected macrosomia, etc. Why then, does no one in the obstetric field or the media connect the dots? If fat women are being induced at numbingly high rates, then it is surely no surprise that they have a higher cesarean rate. The problem is that no one in the obstetric field wants to look at the IATROGENIC influences on the cesarean rate in women of size. Thus, no one ever questions the high rates of induction in women of size nor questions whether reducing inductions might reduce their cesarean rate too.

If you look back at the historic literature on obesity and pregnancy, you often find that the cesarean rate was NOT higher in women of size, or only slightly higher. Certainly not the sky-high rates it is now. Cesarean rates have increased in all women, it’s true, but much more disproportionately in women of size.

I believe this is because of the way that fat women’s pregnancies are managed now, with high rates of induction, strongly encouraged early epidurals, restricted mobility in labor, and a very low threshold for surgery etc. Also, many doctors don’t realize that fat women tend to have longer menstrual cycles and so don’t adjust their due dates accordingly, making for more “postdates” inductions. And finally, there is an exaggerated sense of risk now around obesity in pregnancy, with doctors increasingly adopting “scorched earth” tactics and extreme protocols for women of size. Thus the push for specialized centers for fat pregnant women, in effect ghetto-izing them to high intervention and high-risk management.

None of this is to say that there aren’t possible and real concerns about pregnancy in women of size. Of course there are, and a higher rate of pre-eclampsia and GD is going to lead to some of those inductions….but the majority of those inductions are pre-emptory, not based on actual complications. And proactive prevention via the midwifery model of care goes a long way to reducing these problems and giving a greater chance for a normal pregnancy and normal vaginal birth. The fat women I know who go the high-tech, high-intervention route end up with a LOT more cesareans than the fat women I know who go the low-tech midwifery model route. It doesn’t prevent all problems, of course, but it does help a LOT. But increasingly, fat women are being socialized away from or even legally KEPT from access to the midwifery model of care.

I have written many times about the cesarean rate in women of size, why it is so high, and what women (and providers) can do to lower the rate. You can read more about this (with research citations) in the article I wrote for Our Bodies, Ourselves at:

http://www.ourbodiesourselves.org/book/companion.asp?id=21&compID=125

The bottom line is that doctors are human. They don’t like to acknowledge that they (and the way they practice) are part of the reason why the cesarean rate is rising so strongly. So they look for other, outside factors to blame. For a while it was all the women “choosing” elective cesareans. Or women delaying childbearing. Or the increase in multiples from fertility treatment.

One of the reasons that gets the least pushback is the obesity epidemic. It’s the perfect scapegoat, because it’s everyone’s favorite target and rarely is it questioned, even among many natural childbirth advocates. Critical thinking does not get applied to the research, and no one questions conclusions….like all those cesareans being performed on fat women MUST have been necessary ones. So my prediction is that we’ll see a lot more of these stories in the future.

Just keep in mind that when you see a story like this, you are seeing a masterful blame deflection job. Yes, there are real questions and concerns to address about “obesity” and pregnancy, but beware of letting it be blamed for the cesarean epidemic in the country. The story is far more complex than that….but rarely is it presented so.

 

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Reader Comments (11)

Of course there are, and a higher rate of pre-eclampsia and GD is going to lead to some of those inductions….but the majority of those inductions are pre-emptory, not based on actual complications. And proactive prevention via the midwifery model of care goes a long way to reducing these problems and giving a greater chance for a normal pregnancy and normal vaginal birth.

YES - THAT!! *applause*

August 22, 2010 | Unregistered CommenterErinn Streeter

2 of your 3 comments look like SPAM.

I appreciate what you are saying,and really want to share it with women, especially women of size, because I STRONGLY believe you are right. I am sure that this happens on a regular basis. I even argue that people who are heavier are targeted and discriminated against (unnecessarily) all across medicine. I know there are instances where size is relevant to medical treatment, but in medicine, and obstetrics in particular, it seems that no matter the issue "it's because you are obese (and the definition for that is unbelievable wide)." Also the medical culture lacks faith in women but especially in big women. Bigger women are viewed as gluttonous and lazy and/or uncaring and selfish (at least that's how they treat you). It's sad, and unfair. Someone I love was even blatantly told- "your baby will die if you go post dates BECAUSE your fat," with no other reason at all.

I have one little problem, which I hope I can express gently. It might come across a little smoother and more sympathetic if you replaced all of the "fat women" or women who are fat" with your other term "women of size." The word "fat" as an adjective might come across to some as derogatory.

August 22, 2010 | Unregistered CommenterWhittney

Being a fat mom myself and having to fight for a VBAC was a nightmare. They really do treat you as though you are some ticking time bomb, even when all tests are negative, all vitals are fine ... they STILL keep telling you over and over that you SHOULD induce, you COULD have a big baby (even when your u/s are clearly showing that is not the case and I don't think babies just suddenly explode like popcorn kernels). It was absolutely ridiculous and I ultimately fired my perinatologist at 36 weeks because, even that late in my pregnancy, she was still trying to convince me that I was going to develop preeclampsia again (that is why I had a c-section with my first child), that I could still have GD (in spite of me going through not one, but 3 GD screens at her demand!) and that it would just be sooo much easier if I let her schedule me for an elective c-section. When I questioned how or why that was safer for myself or the baby, taking into consideration that the risk of infection, of cellulitis, of severe scarring, of fetal injury is more likely in an obese mom ... why would I want to do that? I had a completely routine, uneventful pregnancy aside from really awful nausea (which made my doctor *compliment* me on not gaining any weight, because vomiting so much that you lose weight while preggo is so healthy right?) and yet spent the entire time under the threat of a c-section for absolutely no reason other than my size. It, to put it mildly, pissed me off. Badly enough to ditch my doctor.

August 22, 2010 | Unregistered CommenterMariah

WRM continues to pull me back from the medical hysteria about fat birthing.

(And the word "fat" isn't a negative adjective to many fat women, myself included. It's an apt description. Using the "softer" terms cloaks the word "fat" into a shameful, embarrassing place. I don't live there.)

As a fat provider, this is certainly a topic that's come up over and over in my life, including my own pregnancies and births. I try to read everything I can regarding obesity and pregnancy, birth and breastfeeding. Not to impart the fears of many of the articles onto clients, but to try and decipher what will and will not be great information for all of us, providers and clients. I am the first to admit that I speak loudly about the possible (NOT probable) complications of fat in childbearing women, including amenorrhea, GDM, macrosomia, sd, inadequate milk supply and the really difficult and painful post-cesarean complications, but I also talk about ways to create a great pregnancy that lowers these risks (oh, please don't say, "with diet and exercise, right?". I think those two words are vulgar.) Is there a better way to talk about it? I try.

To me, what's insulting is a white-coated OB standing with one hand on the door and saying, "Oh, you're too fat/Eat less/Go to the gym/I've scheduled you for another GTT/Schedule a cesarean at the desk/etc." I (like to) believe that those of us who work within the midwifery model (as WRM talks about) are able to *see* women as individuals, to discuss the issues, not just amplifying risks until the are the giant beanstalk in the land of Lilliputians.

So, reading the original article and then the follow-up comments, including this one from WRM provides balance that is necessary, not just in my world, but also calms women, helping them to take a deep breath and see that they are *not* doomed to every complication mentioned with the word "obese," but can be (and *should* be) seen as a healthy pregnant woman who happens to be fat.

August 23, 2010 | Unregistered CommenterNavelgazingMidwife

Oh man, gotta love the workout spam. Thanks a pantsload, internet robots.

I'm fat (see NGM above for my feelings on the word "fat"), and the year I gave birth, I had three close friends give birth, two of whom were sized similarly to me. One had an 8 hour unmedicated labor and a water delivery; one had a grueling (and actually totally necessary, pre-eclampsia) 3-day induction. Despite the induced mom's steadily worsening enzymes and bloodwork labs, her provider kept close tabs on her (non-distressed) fetus, and while it was a squeaker at the end, mom delivered vaginally. The little dude did need some oxygen and vigorous rubbing to actually cry and pink up, but his 1 and 5 minute Apgars were 4 and 9, and he is a vigorous happy 4-year-old today.

It was absolutely choices her provider made that enabled her to give birth vaginally. Her OB oversaw the placement of three prostaglandin gels over the course of the three days, and made the decision to turn her pitocin up EXTREMELY high (30 nmol/hr), albeit extremely gradually. And when that didn't work, instead of cutting her, they gave her another gel treatment and sent her home to ripen a little more. Basically, even though she was induced at 38 weeks with a hard, long, closed cervix and a very high baby, they gave her every possible chance to deliver vaginally, rather than hopping straight to a section. I actually passed that OB's name along to my midwife practice, because sometimes there are genuinely high-risk pregnancies (my friend's blood pressure was already getting out of control by 14 weeks) that genuinely need the services of an obstetrician, and it's good to know that some exist who are passionate advocates of physiological birth.

But what if the OB hadn't pushed for it? What if fatphobic providers had demurred at placing multiple cervical gels on a fat woman, for only personal aversive reasons? What if they'd assumed that section was a foregone conclusion, and reacted sarcastically to her attempts to get things moving without pit? What if the one L&D nurse hadn't provided seriously six hours of tailbone counterpressure against unmedicated pit contractions, or the other hadn't used a knotted-up bedsheet to play tug-of-war to give her something to push against? What if they'd taken one look at this pre-eclamptic fat woman and started scrubbing for surgery?

August 23, 2010 | Unregistered CommenterKathryn T.

Thanks for highlighting my comment, Jill! And by the way, I have a new post up today about stories of size bias towards women of size in pregnancy and birth. http://wellroundedmama.blogspot.com/2010/08/please-document-your-stories-of.html I didn't have it scheduled for today but it seemed like a good follow-up to our discussions here so I put it up a little earlier than planned. I hope women will follow my suggestions and document any stories of weight bias and mistreatment they have experienced.

Whittney, thank you for sharing your concern about terminology. It's one of those difficult questions for which there is no perfect answer. Let me explain why I use the terms I do.

The correct medical term is "obese" but there are very few of us who qualify for it who actually like it. Many of us (but not all) feel it pathologizes weight, esp "morbid obesity." Personally I hate that term. I also loathe the word "overweight" because it judges me by someone else's standard.....and a standard my body could never meet no matter how much I tried....not with a "healthy lifestyle," not even with insanely restrictive dieting. So I particularly dislike those words.

Lots of people use euphemisms for fatness (heavy, curvy, rubenesque, fluffy, plus-sized, zaftig etc.), but those just dance around the issue and most are condescending to boot. Many people in the fat-acceptance community hate euphemisms.

So there was a move to reclaim the word "fat," to strip it of the negative associations and reclaim it for what it really is, simply a physical descriptor of size/weight. In fact, "fat" is the term I prefer. By reclaiming it for ourselves, we don't pussyfoot around the issue; we simply use what should be a neutral descriptor, without judgments.

However, I deal in the real world. Some people have such negative associations with "fat" that they couldn't hear any size-neutral message around it.....and there are those people in the world who would *literally* rather die than have the word "fat" associated with them. It's not enough to just preach to the converted; I want others to hear the size-friendly message too. And there are practical considerations as well, like using terms (like "obesity") that most people will use in search engines.

So what I've done is compromise and use a variety of terms to reach a wildly varied audience.

I use "fat" for readers already on board with fat-acceptance and because I want to push the envelope for its acceptance outside the FA community. Even though it turns off a few outside people, it's very important and empowering to reclaim it. Remember, "fat" is not a 4-letter word. It's just a descriptor, and the more we use it neutrally, the more negative power we take away from it.

But I also get readers who are medical professionals, and they want the standard of their profession, "obese." I loathe the word but I accept it as a necessity to be found more easily on search engines and to be taken more seriously by medical professionals. When it Rome etc...I use the language of medical professionals particularly when giving presentations at conferences or when discussing research online. I often use "scare quotes" around it online to indicate my displeasure with the word, though.

I also get lots of readers who are new to fat acceptance so I use some euphemisms to make them more comfortable. My favorite euphemisms (because they seem most neutral and least cutesy) are "plus-sized," "heavy," "large," and "people of size." (I didn't like the latter at first but it has grown on me and seems to be accepted by most readers so I use it a lot now.)

So yeah, terminology can be a difficult topic when discussing weight. Whenever I speak at midwifery or childbirth conferences, I always begin with a brief summary of the above so people can get past their judgment of the terminology and hear the actual message.

I usually encourage healthcare professionals to be aware of the implications of various terms, but in the end to respect the terminology their clients choose for themselves, whether that's "fat" or "obese" or "overweight" or "heavy" or "plus-sized" or whatever. If you don't know their preferences, try to stick with one of the more neutral euphemisms until you establish what they prefer.

Hope that clarifies my usage a little more.

August 23, 2010 | Unregistered CommenterWellroundedmama

You will all have to forgive me for my lack of knowledge on the terminology trend. In most of my experience, "fat" was definitely a word used with only cruel intentions.

August 24, 2010 | Unregistered CommenterWhittney

PS thanks for taking the time to explain :)

August 24, 2010 | Unregistered CommenterWhittney

Whittney -- like all reclaimings, it's a fraught process. I am having to explain myself, constantly, wherever I go, particularly to my care providers; the phrase I use is "I am trying to reclaim 'fat' as a value-neutral descriptor, like 'tall' or 'brunette,' so as to avoid the sense of shame I feel euphemisms bring to the experience." It took me a long time to get here, and a lot of picking through personal minefields. Not everyone's journey towards size acceptance necessarily takes them to the same place; for me, it was a recognition that the reason the word "fat" hurt so much is because it was undeniably true, and a decision to remove the stigma rather than the word. But not everyone is going to come to those same conclusions, and that's good; it helps contribute to a well-rounded (ha!) and diverse movement.

(Interestingly, not all my care providers can get on the wagon. Both my midwives can; my shrink can, after some personal effort; my PCP can, all the nurses in my clinic can, and my nutritionist can. But another physician in my clinical practice, a woman who's probably 15 or 20 pounds over her ideal weight but not observably fat -- she just can't do it. She has apologized to me, but she just can't. She uses the phrase "bigger" instead, which I'm also OK with.)

August 24, 2010 | Unregistered CommenterKathryn T.

Whittney, no worries. I totally understand. When I was young, "fat" was only used with cruel intentions around me too.

But that's precisely why it's so powerful now to strip it of its stigma and use it simply for what it is, a neutral descriptor of size.

But you get to self-define. Use the term you are most comfortable with if you prefer. But it's also interesting to take a moment and reflect on what the underlying implications of the words are, and see if altering your usage has an impact in your life or sense of selfl-esteem or empowerment. Altering terminology can sometimes be powerful stuff.

Blessings on you whatever you use.

August 26, 2010 | Unregistered CommenterWellroundedmama
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