Fat Phobia

I was a bit flabbergasted by this article from the UK: Fat mothers to be banned from hospital: A hospital has banned fat women from giving birth at its maternity ward.

Mothers-to-be who have a body mass index (BMI) of over 34, the equivalent of an average woman of 5ft 6ins weighing 15 stone, will be turned away from Weston General Hospital, Weston-super-Mare, Somerset.

Here’s a BMI calculator. One “stone” is equivalent to 14 pounds, so “15 stone” equals 210 pounds. I weighed more than that when I gave birth at home to each of my babies.

Instead patients will have to travel 20 miles to the nearest full-facilitated maternity unit at St Michael’s Hospital, Bristol.

A spokesman for Weston General Hospital said it was not equipped to handle complicated births.

But they cannot know which normal labors will become complicated. Even assuming that they are correct that fat women are at increased risks (listed below), there are normal-weight women who will also face complications during labor and birth. Last time I checked, umbilical cord prolapse and fetal distress were “equal opportunity” problems, not related to one’s weight.

“Our foremost concern is for the safety of mothers who deliver here and their babies.

Yeah, that sounds nice and everything, but if you can’t handle labor complications, you can’t handle labor complications! Right? And if you can, you can — right?

“Mothers with a high BMI are at increased risk in labour of bleeding, needing an instrumental delivery or complications, such as the baby’s shoulder becoming trapped behind the pubic bone.”

How much increased risk? Even if it’s double the risk on all of these, if only 1/3 of mothers are in this high-BMI group, the actual occurrence of these would be the same number. Let’s say out of 10,000 women giving birth in this hospital every year or every decade (totally hypothetical — it actually sounds like a small hospital, so may have a very low rate of births), 3,000 of them have a BMI of 34+. If the rate of any of these complications is 1/1000 for the normal risk group and 2/1000 for the other group, then out of these hypothetical 7,000 below-34 BMI, there will be 7 complications, and for the 3,000 over-34 BMI, there will be 6 complications. Why is it that they can handle this number of complications from normal-weight women, but not a similar number for over-weight women?

How much increased risk in actuality as opposed to merely the fear of increased risk? Often, the increased C-section rate is blamed (at least partially) on increasing levels of maternal obesity. But as Jill at The Unnecesarean pointed out, “cesareans do not occur spontaneously. An obstetrician performs them.” And when a C-section is performed, the assumption is that it was necessary. When a C-section is even merely recommended, the assumption is that it is necessary. And when doctors are trained that women of a certain size are ticking time bombs, or “C-sections waiting to happen,” what are the odds that they will find some excuse, any excuse, to get “the inevitable” over with? Henci Goer pointed out in some research (I’ve lent out my copy of Thinking Woman’s Guide, so can’t get the precise reference), that when doctors believe a fetus to be large, they are more likely to diagnose cephalopelvic disproportion (or give some other excuse for a C-section), even when the baby is normal size; and when they believe a fetus to be normal size, they will let vaginal birth continue, even though the baby is actually large. The doctor’s beliefs about the baby’s size are more important than the baby’s actual size. Similarly, if doctors believe that “fat women can’t have vaginal births,” how often do you think they will find some “reason” for her to have a C-section, even though they would have let a normal-size woman with the same clinical findings (length of labor, fetal heart-tones, etc.) continue to labor and ultimately have a vaginal birth? And C-sections are a risk factor for blood loss and hemorrhage.

What is the actual increased risk of shoulder dystocia (the baby’s shoulder becoming trapped behind the pubic bone) among obese women? According to this 2003 ACOG publication,

“For obese nondiabetic women carrying fetuses whose weights are estimated to be within normal limits, there is no increased risk of shoulder dystocia.” [emphasis mine]

What about the need for instrumental delivery? Perhaps it might have something to do with women of size being even more likely to be restricted from moving during labor, and adopting the best positions that can reduce the risk of shoulder dystocia, the need for a C-section, and the need for instrumental delivery. (Well-Rounded Mama has many posts on the topic of being fat and pregnant including “Crisis of Confidence” and “Scare Providers.” Updated to add this post, which she brought to my attention in the comments. And updated again to include the link to the post she mentioned in her comment, written in response to this post.) And as with the above paragraph — it may have more to do with the doctor’s or midwife’s preconceived notions about a fat woman’s “need” for an intervention, rather than actual indication for it. A self-fulfilling prophecy. But even if it’s higher, is it that much higher to require that all women above 34 BMI give birth in another hospital? What if 1% of all normal-weight women will end up needing a vacuum or forceps-assisted birth, but 2% of all obese women do? That’s certainly an increase — “double the risk” — but it’s still fairly low. If this hospital can handle instrumental deliveries in normal weight women, why are they suddenly unable to do so in obese women?

And as for increased risk of bleeding, I will assume that they’re talking about postpartum hemorrhage, since intrapartum bleeding is rare and is associated with conditions like placenta previa or placental abruption. There are several risk factors for postpartum hemorrhage, but maternal obesity is not listed as one of them. However, being Asian, having a previous stillbirth, and having an epidural were listed as risk factors. I wonder if this British hospital will not allow epidurals, due to the increased risk of postpartum hemorrhage. How does the hospital handle bleeding in non-obese women? How would that handling be different in obese women?

~*~

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13 Responses

  1. So… I was 218lbs when I delivered Zoë just three weeks ago. Non-diabetic, no high BP, all tests clean and clear. I pushed her out in about a minute without any tearing.

    I understand obese women are at greater risk for many issues and problems. But it makes it sound as though anyone who is fit and in their appropriate weight bracket won’t ever have any issues whatsoever. It’s impractical to assume that people of a certain weight will be higher risk than those who are not.

  2. Wow. Glad I am 5’9″ ….

  3. Wow! This is crazy!! I’m not a big girl myself. The most I ever weighed was 155 at full term but uh, I’d be LIVID if I was banned from a hospital because of my size. They’re going to get more and more ridiculous, aren’t they?

  4. Instrumental delivery, what would that be, piano, saxophone, violin, tuba? Sorry I couldn’t resist a bad pun! Seriously though, is that BMI their pre-pregnancy size? Or their current pregnant size?

    • LOL!

      I would say that the BMI would be their current size, although the article does not make it clear. It *sounds* like a current pregnancy weight, though.

  5. On another forum I’m on, a link to this was posted and a couple of other people wondered the same thing about the BMI. The thing is, the really need to rethink BMI – it can list football players who are big and bulky from weight lifting as morbidly obese which is very wrong.

    The thing that is so scary is the amount of power these institutions have, or at least that’s the way they’d like to come across. Did you hear about the woman who left her husband and children so that she didn’t have to have another c-section? Or about the woman who got a section because the nurse (who was not really trained) swore she felt the baby’s elbow? No doctor checked her or anything and she was just popped up on the table and cut open.

    I live in Britain and I can tell you that from my personal experience, the rate that they quote for c-sections is way off! They say that it’s only 25% – most of the women I knew who had babies at around the same time as me – the rate was 50%. Some of them are part of the ‘too posh to push’ group and others had ‘emergencies’ and others had ‘medical reasons’. I just noticed that they are giving them out like candy and it’s frightening.

    The good thing though is if you have access to it, the NHS will pay for a mid-wife to do a home birth. That is a mid-wife from the hospital who comes. You go to all your appointments with the mid-wife in the doctor’s office and then shortly before your due date, they bring a lot of equipment over to your home so that she’s not doing a mad dash rush.

    It is however going the way of the ‘liability risk’ and compensation culture mentality and so everyone is afraid of lawsuits. There are signs up all over the place and the signs are taking away people’s ability to think for themselves and so common sense is dying.

    • Yes, about the first time I heard about BMI, it was in the context that Arnold Schwarzenegger would be considered obese (or morbidly obese?) based merely on his height and weight, although he was almost all muscle. Here’s a project that shows what people of various BMIs really look like — most of the “underweight” BMI people look like they just left Auschwitz; the low-normal and normal people look skinny and thin; the “obese” look fairly normal; and the “morbidly obese” look fat (but not horribly so).

      Yes, I heard about Joy Szabo in Arizona who is staying with friends apart from her husband so she can be living close enough to a hospital that allows VBACs. And, I just read yesterday about the second woman you mentioned — incredible!

      That’s one thing I’d like to see more of here in the US — more access to midwives and also home births.

  6. That sucks because I would have been banned for sure. The basic BMI calculation (not measurement) can produce some skewed results in certain people.

  7. On a somewhat side note that many people had mentioned, the standard ‘height weight’ chart to measure BMI that they use in doctor’s offices is ONLY SUPPOSED to be used on people who are of ‘average fitness’ (If I remember the meaning correctly its people who fall in the 3 workouts of 30 min a week or less). For people who are particularly athletic (like Arnold or those football players mentioned) there is a different way of measuring it that gets more accurate readings (plus or minus 1% off a water float BMI when the height/weight chart can easily be off by 10 points or more). When I was in track, running 5 plus miles every day the hieght/weight and caliper measures of BMI had me around 25. When done appropriately to my athletic level (muscel mass) I was around 12 BMI. I am annoyed enough about doctor’s who don’t recognize the basic fact that ‘muscel weighs more than fat’ when they look at those stupid little charts, I find it difficult to comprehend how anyone smart enough to get through medical school could think that a height/weight chart is sufficent to calculate BMI for a pregnant woman! For goodness sake, that weight isn’t even all HER! And there is increased blood volume, fluid volume, etc etc etc. What a perfect example of doctor’s letting their ‘intelligence’ overwelm their COMMON SENSE!

  8. Speaking of BMIs reminds me of this post on “My OB said WHAT??”: a woman was having a regular contractions at 34 weeks, and called her midwife, who asked her what she was drinking. When she said she was drinking juice and water, the midwife asked her what she weighed. 160 lb was the answer. The midwife said she was overweight and shouldn’t be drinking any juice. “I’m 6’3″!” the woman replied. The midwife answered that it didn’t matter how tall she was, she was still overweight. Sigh… :-/

  9. This is part of a new trend towards “bariatric obstetrics.” The idea is that the “obese” mother is at SUCH INCREDIBLY HIGH RISK that she is better off delivering at a hospital that is specially equipped for her needs and where doctors can specialize in such “high-risk” deliveries.

    Although some folks setting up these policies may have good intentions, what they are doing s ghettoizing fat women.

    By taking away low-risk care options for fat women, they virtually guarantee a high-risk, high-intervention, high-complication delivery for them.

    But no one is studying whether switching to special “bariatric obstetrics” practices and units and hospitals actually improves outcomes among obese women. They just assume it does, and I’d bet that the centralizing of these women together leads to an atmosphere of unchecked intervention.

    I have some posts on my blog about the trend towards bariatric obstetrics. I think that more and more, we will see fat women denied the right to obtain low-risk maternity care, to see midwives, to have home births or birthing center births. Some regular OB practices now refuse to care for “morbidly obese” women (BMI greater than 35 or 40, depending on who’s defining it) and require all of them to see high-risk specialists….regardless of whether they actually have any complications or not.

    The hyperbole of risk around fat mothers is so extreme that we are now ghettoizing them.

  10. I actually got so ticked off writing about this that after thinking about it a bit, I decided to take my reply and turn it into a larger post. It’ll be up in the next week or so on my blog, http://www.wellroundedmama.blogspot.com.

    And here’s the link to my previous post on “Bariatric Obstetrics.”

    http://wellroundedmama.blogspot.com/2008/07/bariatric-obstetrics-part-1.html

    Here’s the post Well-Rounded Mama wrote in response to this post.

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