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Tuesday
May172011

Should Providers Refuse to Treat Overweight Pregnant Women?

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By ANaturalAdvocate

Various media sources (including social media) have been abuzztoday regarding news of some ob-gyns in Florida refusing treatment to some patients on the basis of weight/BMI alone. The Baltimore Sun article on this practice is one of the more detailed pieces to come out; please read the original article here, as only portions will be dealt with here. 

Now, for the “fisking.”

In a nation with 93 million obese people, a few ob-gyn doctors in South Florida now refuse to see otherwise healthy women solely because they are overweight.

It is important to keep in mind that these women are being denied care *solely* as a result of being obese/overweight, before developing any particular complications related (or not!) to their weight.

Fifteen obstetrics-gynecology practices out of 105 polled by the Sun Sentinel said they have set weight cut-offs for new patients starting at 200 pounds or based on measures of obesity — and turn down women who are heavier.

While this isn’t a terribly scientific method of inquiry, it’s still over 10% of the area ob-gyns interviewed who felt it necessary to develop weight guidelines for accepting patients. It is unclear here whether the women are denied care if they are/were above the guidelines before pregnancy or if they reach them during pregnancy as well. A cutoff of 200 lbs. could impact a number of women, both before and during pregnancy, particularly women who already tend towards that end/are taller/athletes/etc. It is also unclear how “obesity” is measured, although it is assumed that the ob-gyns use BMI to determine whether a woman should be denied care. The problems with BMI (and pregnancy) have been dealt with here, as well as at The Well-Rounded Mama and a number of other blogs. 

“People don’t realize the risk we’re taking by taking care of these patients,” said Dr. Albert Triana, whose two-physician practice in South Miami declines patients classified as obese. “There’s more risk of something going wrong and more risk of getting sued. Everything is more complicated with an obese patient in GYN surgeries and in [pregnancies].”

People don’t realize the risk we’re taking by taking care of these patients.” Would these people be the pregnant women, taking their own risks in pregnancy and childbirth? And why are the risks of the situation focused on the physicians, and not the patient? If the reason that these ob-gyns are turning down patients due to weight is because of complications, why not deal with that? Ah…”more risk of getting sued.” Dr. Triana’s practice also declines “obese” patients, which can range from a very unhealthy person prone to complications to, say, an athlete.

Plantation ob-gyn partners Jeffrey Solomon and Isabel Otero-Echandi turn down any woman weighing more than 250 pounds.

Solomon and Otero don’t want to begin seeing heavy women and then have to send them to specialists if they later develop problems, said their office manager, who asked not to be named. The two doctors, like several of the others with weight cutoffs, declined to comment.

These two physicians do not want to later have to refer women out; what do they do with patients who develop actual complications later in pregnancy? One presumes that they refer them out to the needed specialists. 

“This is not a high-risk practice,” the office manager said. “They are not experts in obesity.”

If the ob-gyn’s office is not high-risk, whom is it designed to handle? In addition, is there a specialty in pregnancies of obese women? If not, then to whom are these women being referred, since the regular ob-gyns - the people trained to assist in higher-risk births - are refusing to see them? The hospital the practice refers to had, in 2008, a Cesarean section rate of 46.7%, significantly above the state average. 

Turning down overweight people is not illegal for doctors, but the policy worried leaders of physician groups, medical ethics experts and advocates for the obese, all of whom said it violates the spirit of the medical profession.

While it is completely understandable to refer patients out if a practice if unable to take care of them, it is something else entirely to deny women care simply because they might possibly have complications at some point. 

So far, the weight cutoffs have been enacted only by South Florida ob-gyns, who have long complained of high numbers of lawsuits after difficult births and high rates for medical-malpractice insurance. More than half go without coverage.

It is interesting that an area decried by the doctors as having a high rate of lawsuits, and where many of the doctors do not carry malpractice insurance (!!!) is one of the same areas where women are constantly faced with a lack of choice around pregnancy and birth. 

Several ob-gyn offices said their ultrasound machines do not give good images of internal anatomy in obese women, making it harder to diagnose medical problems. 

A lack of appropriate equipment is an understandable reason to refer someone out - for that procedure, much like patients are referred out for x-rays, CT scans, and even ultrasounds during pregnancy, as many offices only maintain older or more basic equipment in office, referring out for detailed images. 

The Plantation office manager said weight limits are not uncommon at offices owned, like hers, by the Coconut Grove medical services company VitalMD.

VitalMD Group Holding, LLC describes itself as “a large group practice focused on delivering high-quality women’s health care. Founded by an expert team of savvy physicians and business professionals, VitalMD was formed to help its physician members achieve their financial, operational and clinical goals through the group practice model while allowing them to refocus their time on providing quality patient care.”

VitalMD treasurer Kerry Kuhn, an ob-gyn in Coral Springs, said he was unaware of his doctors setting weight limits, adding the company has nothing to do with doctor decisions.

“This is individual choice by a doctor,” Kuhn said. “Doctors know who they want to treat.”

Doctors. know. who. they. want. to. treat. 

Doctors also are allowed to drop patients, if they believe they lack the medical skills to properly treat them. They must send notices and refer them to other doctors.

If this significant a proportion of physicians are unable to properly treat obese/overweight patients, it begs the question as to why these professionals are not trained to treat these patients. 

But decisions about patients typically are made after assessing the individual’s condition during an exam, not by ruling out an entire group, said Dr. Robert Yelverton, a board member of the Florida Obstetric and Gynecologic Society. He said he would discourage physicians from excluding the obese.

“Do I think it’s a good policy? No,” Yelverton said. “Overweight people need doctors. I don’t know where a patient in that situation would go if every practice had that policy.”

———————————

Do you know of any physicians/midwives who use the same or similar criteria in accepting patients for care? Have you been denied care as a result of your weight or BMI? Are you a provider who denies care to patients not meeting certain weight/fitness guidelines? 


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Reader Comments (35)

Oh dear, women who won't do as they're told are out, fat women are out - won't be anyone left for these doctors to work with soon! What happened to doctors providing doctoring for whoever came along in need of their ministrations? I just don't get this attitude they're displaying here. Is this a random group of doctors we are hearing from in this story?

May 18, 2011 | Unregistered CommenterCarolyn Hastie

As a mom to 4, I would have been turned down by these docs for coverage in my last 3 pregnancies... ironically (or not!), my only c-section was my FIRST baby, who was also my only baby delivered by an OB. My subsequent 3 were caught by midwives, and the last 2 at home. I'm 5'8" and big boned, and my weight hovers within 2 lbs of either side of 200 lbs and has for the past 10 years, though anytime I divulge that info people are inevitably surprised and say I don't look like I weigh 200 lbs (whatever that means, lol). I walk 30-45 minutes in our hilly terrain 3-5 times a week, I eat VERY healthy, and I'm still too much of a risk according to these ya-hoos. My hope would be that this idiotic policy only brings more women to seek evidence-based care from a qualified midwife!!

May 18, 2011 | Unregistered CommenterSouthrnMama

Did you miss the bariatric obstetrics post on WRM? http://wellroundedmama.blogspot.com/2008/07/bariatric-obstetrics-part-1.html

May 18, 2011 | Unregistered CommenterCassandra

When PG w/my youngest I started seeing a local MW that worked out of a Birthing Center. I was planning a Homebirth. Halfway through my PG her practice merged with another group of MW. The "new" MW were unhappy w/my choice to HB & my MW choice to "allow" it. This was based on my size alone. I am not "overweight" or obese. I go the other direction. At 5'7" & pre PG weight 100lbs, I am small. Severely underweight based on charts & BMI. They recommended ultrasounds and "routine" bloodwork beyond what would normally be done. Not because I was presenting with symptoms or conditions that would warrant it, but simply because of my size/weight. It was assumed that since my weight wasn't typical that it wasn't normal or healthy. It was anticipated that, based only on my size, I would have problems growing, carrying and delivering my baby. The fact that I had already carried and grew 2 healthy babies and had a successful VBAC w/a baby w/a 14 1/2" head didn't seem to matter as much as my size. I had to stress to them over and over that my size was normal for me. In the end, I refused the extra US & bloodwork. My original MW supported me & my decision to HB. My 7lb baby was born at home at 39wks 1day. With no complications. So, as someone on the "outside: range of what's considered a normal healthy weight, based only on their chart & numbers, w/no consideration for my actual health, the idea that providers could/would use weight alone to refuse patients is troubling.

May 18, 2011 | Unregistered CommenterSara W.

Seriously, what's wrong with Florida? The more I read about Florida the more it makes me glad I don't live there. My midwife said nothing about my weight. My "obese" self had a VBAC just fine at home. Hasn't BMI been totally debunked as acurate, yet? The only real way to measure obesity is through a series of tests that measure your actual fat Height/weight ratio is just accurate. Some of us are more dense :-)! At least that's what I tell myself.

May 18, 2011 | Unregistered CommenterSteph G.

Sorry, meant to say "height/weight is just NOT acurate"

May 18, 2011 | Unregistered CommenterSteph G.

so when the racist hear this they will want segregation back, what if I hate people with blue eyes, I don't have to serve them because I think they have more eye damage because they have blue eyes which are more sensitive to sun damage. I was over 200lbs with my son because my start weight was 180 +12-15 of fluid and swelling+ 10lbs 3 oz of baby boy and the 2 lbs of extra blood and other crap hmmm so I guess I am not worthy of treatment because I am over weight and have a huge child? When is this BS with weight going to stop! They are treating 10 year olds with eating disorders because they are AFRAID to eat! Stop this before you kill us all. Stop telling people they can't be 15-20 lbs over weight, stop trying to fit everyone in a box. I am 5'6" and I am suppose to weigh 89lbs? Really! I am suppose to look like one of the aliens on TV? Big gapping eyes , skin and bones sticking out every where because when I went down to 114lbs people asked me if I had cancer because I look sick at that weight. Why must we be thinner and thinner? Even men today look like rails and sickly. What will happen to us all if everyone ends up being forced to be a size zero then what we can not be over 5 ft and then we can not have green eyes because it's immoral, why are we telling people they must all be the same size and shape, the same color, the height? Have you ever heard of limiting the gene pool? If there are not all kinds of tall, short, skinny, fat and diff. races we will become clones and die off! I refuse to live in a world where everyone looks alike, acts alike and is alike. Being not part of the mold is a good thing!

May 18, 2011 | Unregistered CommenterNeco

I think it's alright for the doctor to have his/her right to choose which patients they want to take on. They are a private business and this is still a free country. BUT I also think it's a mother's right to go find an OB or MW or doula and have the baby wherever she feels the most comfortable having her baby. It's a question of finding the right working relationship among all the variables that present themselves during a pregnancy. There's risks on both sides. -mother of 5

May 18, 2011 | Unregistered CommenterAmy M.

Sure doctors have the right to refuse care to anyone; but we have the right to call them out on it when their reasons seem sketchy. As these do. If they can't provide some data, or some experience (we've been sued when a pregnancy went wrong for obesity-related issues) then they're just making assumptions and frankly, come off as bigots.

May 18, 2011 | Unregistered Commenteremjaybee

This seems to be a function of the way payments are often structured for physicians. If a surgeon receives a bundled payment - a specific amount to cover the procedure and expected follow-up - they will have more profit (or less loss) if the patient has fewer complications and needs less follow-up. In a uniform patient population this is an incentive to do a good job the first time (something missing in fee-for-service), but in a heterogeneous patient population it's an incentive to shed "bad risks". And while the chances that an obese woman will have a good outcome are very good, there is a demonstrable difference in the rates of complications making it on average more time-consuming and costly to care for us. And to the extent that a poor outcome is a prerequisite for a malpractice lawsuit, many physicians are seeking to limit their exposure by taking only patients with the best shot at a positive outcome.
None of this changes how frustrating it is to be treated as a disaster waiting to happen and have more difficulty finding care, but it does explain it and perhaps point to more effective solutions than appeals to fairness and medical ethics.

May 18, 2011 | Unregistered CommenterChristie B
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