Who is the biggest loser?

My freshman composition class just wrapped up a unit of readings about food. We read a wide variety of articles and essays: classic Michael Pollan fare ("Eat food. Mostly plants. Not too much."), arguments for vegetarianism as the most environmentally friendly way to eat, advocates of conventional industrial agriculture, articles about America's obesity crisis, and arguments for genetically modified plants as the future of sustainable agriculture. We also watched Food, Inc. and had a local organic farmer visit our class as a guest speaker.

Our readings on food discussed several perspectives on obesity. Some encouraged better individual eating choices as the solution to unhealthy bodies. Others pointed fingers at US food policy that subsidizes overproduction of corn and thus floods the market with cheap corn-derived foods. Some noted that while cheap, unhealthy food isn't good for our bodies, it is deeply enmeshed in the American economy and thus will be hard to change.  

Last class, I did an activity about reducing excess wordiness, which I called "The Biggest Loser." I had never seen the TV show before, so I did some "research" and watched a few episodes. I found myself simultaneously fascinated and cynical. It was incredible to see the physical transformations the contestants undergo. Despite the annoying reality TV genre, I still felt motivated when I heard the contestants' success stories. You can do it! Rah rah rah! At the same time, I felt cynical because only a tiny minority of people struggling with excess weight have access to a team of personal trainers, dietitians, and physicians--not to mention an all-expenses-paid stay at a weight-loss camp. "The Biggest Loser" both inspired me and deepened my skepticism.

Obesity has its own controversies in the world of maternity care. On one hand, maternal obesity is associated with many pregnancy & birth complications. But we don't know how much of this is simply self-fulfilling prophecy and/or care provider bias and how much is due to inherent risk of obesity itself. Should we strive towards fat acceptance and the concept of being healthy at any size? Is there some kind of reasonable BMI benchmark we should encourage women of childbearing age to reach? Will focusing on individual choices make more of a difference than trying to change systemic failures? Or will it just make overweight women feel more guilty?

Thoughts?
Links to articles you'd like to share?

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Blame the woman

Once again, women are simply too fat and too old, according to this recent article about rising maternal mortality rates in England. Oh, and they have the audacity to want a natural birth--which of course the article didn't bother to define--another alleged culprit behind rising mortality rates!

From the article:

But some medical staff and patient groups also fear the NHS’s policy to encourage “natural” birth without medical assistance is putting women at risk by denying them medical care in pregnancy and labour. Professor James Dornan, director of foetal medicine at the Royal Maternity hospital in Belfast, said: “Nature dictates that one in every 100 women will die while having a baby. The mortality rate in parts of Africa is now about 850 to 1,000 per 100,000. Left to nature that is what nature will do. I believe in women having choice but it has got to be informed choice.

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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.

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