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?
Filed under: labor and birth Tagged: | birth, bmi, britain, C-section, childbirth, complications, fat, fat mother, fat phobia, high bmi, labor complications, maternal obesity, obese, obesity, overweight, shoulder dystocia, uk