Tuesday, October 16, 2007

Too fat and too old

Sometimes I wonder if vaginal birth will gradually go the way of the dinosaurs: extinct.

A friend of mine who works in hospital administration alerted me to a Webinar (Web seminar) that took place yesterday about "Cesarean Delivery and the Risk-Benefit Calculus." The seminar discussed the anticipated 50% cesarean rate by the year 2017--that is 10 years from now. If that is true, this presentation argued, hospitals will need to construct maternity wings with the capacity to handle 50% and higher cesarean rates in the near future.

This presentation said that rising cesarean rates (both actual and anticipated) were mostly to blame because of maternal obesity and age. Quoting from the PowerPoint slides that accompanied the presentation (all referring to the projected future scenario):
  • Larger mothers lead to unhealthier babies
  • Obesity co-morbidities and medications complicate care of pregnant women
  • Rates of gestational diabetes and pre-eclampsia skyrocket
  • Increasing C-section rates cause downstream decrease in pelvic floor disorders (this claim was repeated several times, even though the medical literature reveals that cesareans do not prevent pelvic floor disorders)
Other contributing factors to the anticipated rise in cesarean rates will be:
  • maternal age (which increases fertility treatments, which increases # of multiple births and high-risk pregnancies as well as congenital abnormalities)
  • OBGYN lifestyle & liability issues
Some other predicted changes in maternity care over the next 10 years:
  • The role of midwives moves to prenatal care as cesarean rates increase
  • Insurance will drive midwives to work in large group practices
  • LDRPs will be replaced by LDRs and a large increase in postpartum recovery rooms to handle the 50% or higher cesarean rate
The second half of the presentation was a historical overview of and justification for increased cesarean rates by Dr. Frederic D. Frigoletto of Harvard Medical School & Massachusetts General Hospital. What I found most disturbing were his assertions that increased cesarean rates result in "improved neonatal outcome." Specifically, his presentation claimed that increased cesarean rates had the following outcomes (all of which contradict most of the research on risks of cesarean sections):
  • Lower rates of fetal hemorrhage, asphyxia, birth trauma, mechanical ventilation, infection, and meconium aspiration syndrome, and feeding problems
Is it just me, or does the marketing of a 50% or higher cesarean rate as health-promoting seem very, very creepy? Even when a cesarean is really needed for a true emergency, there is no denying the real toll it takes on mothers and babies. When a doctor performs a cesarean, it's not just an operation. It is the beginning of a new mother-child relationship! It creates an extra handicap, sending the mother home to recover from major abdominal surgery, to deal with the possible emotional and physical trauma of that operation, especially if it was unplanned or unwanted, all while taking care of a newborn.

I am also disturbed by the blame-the-woman mentality. Women are too old, too fat, too demanding (one factor he listed was the "premium baby" factor), too unhealthy...Especially the real negativity towards women of size. The problem with this attitude is that it often becomes a self-fulfilling prophecy.

I've been re-reading parts of Michel Odent's recent book The Caesarean. Here is his take on cesarean rates:

The aim should be that as many women as possible give birth vaginally thanks to an undisturbed flow of love hormones. However, the primary objective should not be to reduce the rates of caesareans: it would be dangerous, if not preceded by a first step. This first step should be an attempt to promote a better understanding of birth physiology and particularly a better understanding of the basic needs of women in labour.
His maternity clinic in Pithiviers was able to keep cesarean rates between 6-7% while simultaneously having some of the lowest perinatal mortality rates in Europe--something other countries were unable to do without a dramatic increase in cesarean rates. He explains why: women at Pithiviers labored in an environment which facilitated the proper timing and release of hormones. Drugs were almost never used. Pitocin was quite rare, only about 1% of labors. Women were free to labor in whatever positions they wanted, with no one telling them what to do. The clinic's highest priority was that the woman felt safe, secure, warm, and unobserved. For more details about his clinic, read Birth Reborn.

I have a PDF of the powerpoint if anyone would like to take a look at it, by the way.


  1. Wow! And what is really sad is that women are accepting this load of rubbish they are being fed about birth. It makes me very sad whenever I talk to a pregnant woman who has no clue what can, and probably will, happen to her when she walks in those hospital doors to give birth. Unfortunately, as soon as they know my views, they discount me as a radical, and quit listening when all I really want is for them to enter motherhood on a positive note, rather than being scared, traumatized, and defeated. Do you find the same thing to be true?

  2. Yes, it's frustrating that some people aren't even interested in learning about the reality of childbirth or what their range of options are or even what the full set of risks and benefits of their choices are. I'm not just saying these things to be annoying or alarmist. I'm not making it up! And knowledge is power--it can't hurt to do your research and have a realistic picture of what you're getting into. I mean, a 30% cesarean rate isn't going to magically go away if you say, "but I trust my doctor. He only does cesareans when they're necessary." You can't escape the consequences of your decision, no matter how much you'd like to ignore them or pretend they don't exist or think you're the special exception. Okay, I must stop ranting and get back to writing my dissertation!

  3. Glad I didn't fall prey to this misogynist line of thinking. At 38yo and well over 200 pounds I should have been destined to a c-section but instead I had a beautiful four hour UC with only my family and best friend present. My baby joined us underwater in dim lighting being only touched by loving hands. My baby is lucky I can see through this thin veil of deception and disempowerment. Praise the perfection of the female body!

  4. Another addendum: I do what I do because I CARE!! I want women to come out of birth feeling victorious and powerful and elated. Now the route to achieving this is different, and some women might come out of their induction/epidural birth feeling fantastic. Good for them. But so many women are wounded. Physically, yes, but also emotionally and spiritually. Women should never come out of a birth with PTSD, which does happen fairly often! They should not ever feel like they were lied to, manipulated, coerced, abused, or even just treated like crap because they wanted something different.

  5. Yay Wendi!! (Is this the Wendi I interviewed a few months back? If so, then congrats on your new little one!)

  6. I am wounded and I appreciate your post, Rixa.

    I was tricked and lied to and cut and abandoned. Twice. It hurts everyday.

    Dr. Odent was so so right. I know I can birth naturally if I am in a safe environment. I have done it before.

  7. I would love to see the presentation, please. (robin at robineliseweiss dot com) THANKS!

  8. I am personally offended by this being a plus-sized woman myself. I took excellent care of myself during pregnancy- I only gained 10 lbs and immediately lost 15 lbs after delivery. If I had gone to a doctor who had told me that I would never be able to have a baby naturally because I was too at risk because of my size I would have been devastated. Instead I gave birth to a beautiful, healthy, 7 lb 5 oz. baby girl naturally with plenty of pelvic room to spare! She didn't even have a cone head! I wouldn't change a thing about my labor and delivery and I think that doctors should assess each person as an individual instead of clumping them into a category- "old" or "fat" or whatever.

  9. Heya!
    A fellow member of the ICAN email list sent out a link to your blog... all I can say is thank you. One in three women end up cut today, and the numbers are only going up. The US is 41st in the world in maternal/fetal birth outcomes.

    Fat, old, young, wealthy, poor, white, black... it doesn't matter. We see every single category listed as a reason for cesarean. The bottom line is, if you go to a surgeon (OB is a surgical specialty) to manage your birth, you are more and more and more likely to end up cut.

    Maybe we're radicals, and freaks, and whatever else, but we've got to keep talking. Woman-to-woman support is the only way this train is going to stop. Thanks for standing up.

    ~~L! (Publications Director, ICAN)

  10. Ugh. It turns my stomach. Not only that this disgusting propaganda is being preached to women as if it were gospel, but that women are dumb enough to blindly follow along with it. I want to make a thousand smart remarks as is my trademark, but I'm just too sad. :(

  11. Yes, doctors are very much "blame the woman" when talking about the c/s rate. That way they don't have to defend their outrageous policies or acknowledge that the huge c/s increase over the years is largely THEIR responsibility, their mismanagement.

    Instead they can blame it on the women being too old, too fat, too short, wanting that premium baby, whatever is most convenient.

    Historically, fat women did not have high cesarean rates. If being fat truly prevented a vaginal birth, it would have prevented it then too. Fat women have been having babies for eons; why suddenly now do they need to be cut open to have their babies? Size bias and interventionist management protocols, that's why. It's how they are perceived and "managed" that has changed.

    Fat women can have babies vaginally. Older women, short women, you-name-it women can have babies vaginally. The key is to choose a true midwifery model of care, don't induce labor, and to promote a well-positioned baby for the birth.

    (fat, old and short and had vaginal births anyhow!!!)

  12. My goodness. That's depressing. I'm going to link to your blog post. So glad an ICAN member made me aware of your post. I would like to receive a copy of the ppt. I'll e-mail you.
    ~ Kimberly

  13. I hate all the fatphobic generalizations and stereotypes.

    What I hate more is the willingness of fat women to accept the blame for a system that is failing all women, but is making special considerations to further set up women of size for disaster.


    this was an AWESOME post.

  14. I think if we (speaking very generally here) were *really* concerned about obesity's effects on pregnancy, why not:
    - help make organic, locally grown food available and affordable to everyone who wanted it
    - fund free or reduced price health clubs (with on-site childcare for members) so that everyone who wanted to exercise could do it, especially women with small children
    - research into causes of obesity rather than treating/reacting to symptoms as they emerge
    - enable adequate social support so that women have the time, money, and freedom to treat their bodies right and to live healthy lives
    - work on eliminating the cultural bias towards anyone over a size 10!

    Any other ideas?

    This is not to say that being overweight is something *bad* that we need to eradicate across the board...so I don't want to offend any of you mamas out there...but really, how is increasing cesarean rates doing overweight or obese women any good? It will only increase their health problems and complications (as it would with any woman, large or small).

    Barb Herrera (aka Navelgazing Midwife) writes a lot about women of size. I don't know if she reads this blog, but her blog archives have a lot to say about this topic.

  15. ps--Kmom, I love your site! It has tons of great information that applies to women of any size.

  16. Wow. The idea of a 50% c-section rate is going to stick with me for a while. Thanks for a great, disturbing post.


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