Are You a Size-Friendly Midwife?
(A Reprint of Kmom's Article from Midwifery Today)
by Kmom
Copyright © 2002 Kmom@Vireday.Com. All rights reserved.
CONTENTS
*This
Article Was First
Published in Midwifery Today, Spring 2002, www.midwiferytoday.com
Fat
women are tired of being marginalized by the medical community.
They tell stories of egregious bias, of being treated as less than human.
They also tell stories of subtle bias, of providers that seem to be
size-friendly but ultimately are not.
The
very thought of a fat woman reproducing is extremely threatening to some people.
Some fat women have actually been told they should terminate a pregnancy
because of their size. One mother was told that her baby would have a heart
attack and die during labor, so she should get an abortion.
Another doctor told a woman that she was too fat to get pregnant, but
that if she did, he would insist that she have an abortion.
Even family members have been known to pressure fat women to abort their
children.
If
a fat woman defies her family and providers and becomes pregnant anyhow, she is
often faced with tremendous pressure to avoid having more. Some women report
strong pressure in the middle of labor to consent to sterilization afterwards.
One supersized woman would not agree to sterilization, so her OB punished
her by using a classical incision during a cesarean, and then told her she
should not have any more pregnancies because her uterus ‘would explode.’
Afterwards, the doctors and midwives took turns coming in
her room and berating her for her size, telling her that she would never live to
see her child grow up, that she would not be able to adequately care for her
child as he grew, and that her son would hate her for being fat.
She has not had any more children.
Fat
women are often punished with harsh treatment for daring to be pregnant.
Some are yelled at during prenatals or humiliated during weigh-ins, and
any problem is automatically blamed on their size.
Staff and even friends and family often make rude remarks about their
increasing size, tummy, shape, etc.
Fat
women experience a higher rate of surgical birth.1 Some of this is
undoubtedly related to higher rates of complications like PIH and GD, but some
of it is due to size bias, both overt and subtle.
Some fat women regularly report that their doctors told them all along
they’d probably need a cesarean or that their fat would prevent the baby from
being born vaginally.
Some fat women have been required to sign elective cesarean permission
forms at the first prenatal exam for no reason other than size.
Other,
subtler forms of bias may raise the cesarean rate for larger women.
Fat women are induced at higher rates than average-sized women, 2, 3
even when only women with normal pregnancies are considered.4 Doctors
are convinced that all fat women will have huge babies, so they often induce for
suspected macrosomia, which research shows can raise the cesarean rate,5
sometimes to >50%.6 In fact, even the suspicion of
macrosomia significantly raises the c-section rate.7 Yet research
that documents the higher rate of cesareans in heavy women almost never examines
the relationship between higher induction rates and higher cesarean rates.
They simply imply that being fat prevents vaginal birth.
Supersized
women are often treated especially brutally, particularly during a cesarean.
When one woman needed a cesarean during labor, she and her husband were
told to prepare funeral plans and asked whether she was an organ donor.
Her providers reduced her to tears and terrible fear just at the moment
that was supposed to be the most joyous for them.
Many doctors seem to feel that supersized women need to be ‘punished’
for daring to have children, or scared out of having any more.
Some
doctors still believe that a classical or low vertical incision is
‘necessary’ in supersized women in order to prevent infection, despite
evidence that a low transverse incision is just as good or better.8
Fat women have been told that they had a vertical incision because after all,
"You are not likely to ever wear a bikini." Or they are told to cheer
up, "At least while they're in there they can do a tummy tuck."
Doctors
also often do not know how best to minimize problems in large women when a
cesarean really is needed.
Suturing the fat layer and/or using a surgical drain lowers the rate for
infections and wound complications in fat women, 9, 10 but many
doctors do not do this routinely.11 Few doctors or nurses know that
the simple step of using a blow-dryer on ‘cool’ on the incision several
times a day can often help prevent infection in large people.
In fact, many complications could probably be reduced if doctors would
just bother to study more how to lower the risks in this group and then utilize
these techniques more often.
Fat
women are often discouraged from a trial of labor after cesarean as well. One
woman was told by her OB that she was overweight and out of shape and she should
not waste her time or his by trying for a VBAC (she found a new provider and
went on to have 2 VBACs, the second one at home).
Women have been told that being overweight prevents having a VBAC, and
one mother was even told that her pudgy tummy made a VBAC attempt dangerous,
because if she ruptured a doctor "would not be able to tell."
Even today, fat women are still often told not to gain any weight during pregnancy, and some are even told to diet during pregnancy. Some modern researchers still report putting their fat pregnant clients on 1200-calorie diets.12 One fat woman pregnant with twins was told to drink “Slimfast” to keep her weight gain down, and another fat mom’s doctor told her to lose 40+ lbs. during her pregnancy. Many women have been harassed by unkind comments about how ‘huge’ they are getting, lectures during weigh-ins, and frequent admonishments that pregnancy "is not an excuse to eat for two." One mother (who weighed about 200 lbs.) was told, “It’s a good thing you kept your weight down. Five more pounds and you could have died!”
On
the other hand, some fat women have been harassed because they didn’t gain enough
weight, even though low weight gain is very common among larger women, and
usually doesn’t seem to harm the baby.
When it comes to weight gain, fat women are damned if they do and damned
if they don’t!
Size
bias can also be subtle. It’s
assuming that a fat mom will almost certainly get gestational diabetes so
therefore she should take the glucose challenge test every month. It’s failing to realize that a regular-size blood pressure
cuff produces artificially high readings when used on a large arm.13 It’s
assuming automatically that a big mom will have a huge baby and must be induced
early. It’s expecting a size 32 woman to have the same fundal
height measurement as a size 5 woman. It’s
pressing too hard during an ultrasound, simply on the assumption that this is
necessary to see through "all that fat."
It’s telling a fat woman that she may never feel her baby move or hear
the baby’s heartbeat because of her fat.
It’s telling a fat woman that her breasts are too large to nurse, that
fat women usually can’t nurse, or that she will be hard-pressed to find an
effective nursing position because of her girth.
Many
midwives believe that such stories only come from doctors, but doctors do not
have a monopoly on fat-phobia. Midwives
have told fat women to diet during pregnancy, to have gastric bypass surgery
before attempting pregnancy, or have harassed them about weight gain.
They have discriminated in many other ways, too.
For example, one fat woman tells of her experience planning a VBAC at a
birth center across from a hospital. Her
midwives knew all along of her size and never mentioned weight as a concern.
Suddenly, at 35 weeks, new reasons were invented why she should not labor
at the birth center. Finally, the
midwives admitted their real reason for directing her to the hospital----her
size. She writes:
I can’t even begin to tell you how betrayed I felt. They claimed it hadn’t occurred to them earlier that it could be a problem. It’s not like I was hiding my weight, I think it’s probably one of the first things people notice, you know? If they had just been honest at the beginning, I would have looked for someone else. So next time, if there is a next time, I really want someone to be up front about any fat issues they have. I can totally accept that there are medical folks out there who will look at a fat patient as a bundle of risks. I don’t think they are right, but I realize such attitudes exist. I just want honesty from the start of the relationship.
Even
midwives who regularly accept supersized clients and who pride themselves on
being more open-minded about size than most can still show size bias.
One midwife confessed that she was concerned about the dietary compliance
of her fat clients, so she regularly made a point of refusing them care to make
them cry, telling them that she could not take them as clients because they
would "break her heart and develop high blood pressure."
When they would come back the next day and beg to be reconsidered, she
felt she had made her point about good nutrition and would consider them as
clients.
This
midwife genuinely cared about these women and did take larger women as clients,
but her approach is still size-phobic because it assumes that all her fat
clients have very poor nutrition, will automatically develop high blood
pressure, and need to be ‘saved’ from themselves. This treatment humiliates them and forces them to beg for
care. Average-sized women can have
poor nutrition and high blood pressure too, but only the fat women were singled
out for this treatment.
Although doctors tend to be more fat-phobic than midwives, midwives can also exhibit size prejudice. All providers need to examine their equipment, protocols, and attitudes to see if they are truly size-friendly.
Fat
women are tired of being marginalized. They
are tired of equipment that doesn’t fit, judgmental attitudes from providers,
unjustified assumptions, lectures on weight loss, and mistreatment based on
size. They want respectful,
dignified treatment that does not discount possible risks but does not assume
them either. They want to be able
to trust their provider to treat them as individuals instead of as
statistics.
When asked what size-friendliness means,
fat women replied:
The
following are some guidelines for becoming more size-friendly in your practice.
Hopefully, they will help each midwife to observe the way she perceives
fat women, question her assumptions, and carefully evaluate the care she plans
for them.
All
fat people are not alike. Don’t make assumptions about why we are fat.
Sure, some people are fat because they don’t get enough exercise or
don’t eat wisely, but not all of us are.
Don’t assume we’re all sitting on the couch, watching TV and eating
chips all the time.
People who are born into naturally slim bodies have a hard time
understanding what it is like being fat or to struggle with weight, but it is
possible for women to eat reasonably, exercise regularly, and still be fat.
Some fat people are fat because they have lousy habits, but it is
possible to have good habits and still be fat, and it happens more often than
you might think.
Don’t
assume we all have eating disorders either.
Some of us do, some of us don’t.
Some are fat because of emotional eating, but some are fat because
of genetics or hormonal imbalances.
Some of us used to be only chubby, but dieted ourselves up the scale and
permanently raised our setpoints.
Most of us are fat because of multiple combinations of these factors.
Avoid simplistic thinking.
Ask about our diet and weight history before making assumptions about
what we need to do.
Individualize our care.
We’ve heard the ‘fat lecture’ many
times before; we don’t need to hear it again.
If it were simple to lose weight and keep it off, we would have done so
by now. It’s not simple, it
doesn’t respond well to ‘easy’ solutions, and it may not even be what we
want. Some fat people do want to
lose weight, but for some being at a stable higher weight instead of constant
yo-yo dieting is the more healthy choice. Don’t
make judgments without hearing all of our history.
We
are not here to try and lose weight during pregnancy; we are not here to try and
reform our lives to fit what you think is best for us.
We are here for pregnancy and for birth, not to be reformed, and not to
have your agenda and opinions imposed on us.
Listen to what we want.
Be
Aware of Your Own Prejudices and Assumptions
Carefully
examine your own beliefs about fat. Do you automatically assume that a fat woman
in your practice is going to develop gestational diabetes or high blood
pressure? Do you assume that a fat
woman is eating large amounts of sugar and junk foods and will need major
nutritional counseling? Do you
assume that a fat woman is going to gain a lot of weight in pregnancy and will
probably need to be strongly reminded to watch what she eats so she won’t gain
too much? Do you feel that you have
to ‘save’ a fat woman from herself?
Do
you really believe that ‘soft tissue dystocia’ exists, that a woman’s fat
can prevent a baby from coming out? Do
you think there’s a point at which a woman is too fat to become pregnant or to
have a baby vaginally? Did you know that women have conceived babies and had
vaginal births at weights over 400 lbs.? Did
you know that while fat women have higher rates of some complications, the
majority of fat women actually have healthy pregnancies and normal births?
What body issues do you have in your life, and how do they influence your perceptions of us as fat women? The sad reality is that some of the most biased treatment comes from women with their own body issues, which influences their agenda for others. Don’t impose your own agendas and opinions on us; let us tell you what is important to us and how we want to birth.
Many fat women report that their pregnancy experiences follow the expectations of the provider. Look carefully at your own policies of management, your own assumptions, and your own expectations for the births of fat women. Open your mind and take things as they come instead of expecting complications or difficulties. Work with the woman to be as proactive as possible, and then accept how her pregnancy progresses without expectations or judgments.
Use
Size-Appropriate Equipment
Do you have equipment to fit all your clients? Do you and other staff know the importance of a large-sized blood pressure cuff and use it without question? If you practice in a clinic, do you have gowns that fit and actually offer full coverage? Do you have a scale that can be adjusted for supersized women? Do you have at least one or two armless chairs in your waiting area for the comfort of your larger clients?
If you do not have equipment that fits all women, get it! Blood pressure readings taken with a regular-size cuff on large arms are artificially inflated, causing treatment decisions based on invalid data! One study found that 37% of obese ‘hypertensives’ actually had normal blood pressure when the correct cuff was used.13 Make sure all staff knows why the large cuff is important, where it is stored, and that it is to be used automatically, without protesting at having to go get it. Many practices have large-sized cuffs but don’t use them; many large women report having to fight to have the large cuff used.
Supersized gowns can be bought, or offices
can allow women to bring their own gowns that fit.
Some offices buy full-sized real sheets to use on those occasional visits
when the little paper sheets won’t do. Large-sized blood pressure cuffs, scale
adaptors, and supersized gowns are all available from medical supply stores or
through size-acceptance companies on the Internet. If you cannot easily afford
this equipment, consider bartering---let one of your fat clients get the proper
equipment for your practice as part of her fee. In short, get the right equipment for the job, and don’t
base treatment decisions on invalid data.
It’s true that fat women have higher rates of certain complications2---being size-friendly doesn’t mean you have to ignore that. It does mean, however, that you do not assume that a complication is going to happen, that you are aware that most fat women actually do not experience complications, and that you do not treat us as a statistic waiting to happen. Be watchful, but expect normalcy.
However, if we do experience a complication, please don’t be judgmental. Don’t assume automatically that the complication is caused by size; average-sized women experience complications, too. Or a hormonal problem like Poly Cystic Ovarian Syndrome that often accompanies fatness may be the real problem instead of the fatness itself. Don’t judge, just be matter-of-fact and open about the problem. Strive to see us still as human beings instead of the complication, and remember to reassure us and emphasize the positive as much as possible.
We are real human beings.
We have the same hopes and fears and dreams for our babies as anyone
else. We are not a statistic on a
page. See us as more than
mathematical projections---see us as the human beings we really are.
Emphasize
Nutrition Instead of Weight Gain Goals
Research seems to show that while the most
optimal weight gain for average-sized women is about 25-35 lbs., the weight gain
range associated with the best outcomes in fat women is about 15-25 lbs.14,
15 However, the highest priority should be excellent nutrition, not trying
to artificially meet arbitrary weight gain guidelines. Eat healthily and well, and the body will gain the amount
that is necessary for that body!
Women
of size report a wide range of weight gains in pregnancy.
Generally speaking, the larger the pre-pregnancy size, the less weight a
woman tends to gain, although of course there are exceptions.
The most common weight gain pattern in fat women seems to be a loss
during the first trimester, then a slow regain of the weight lost during the
second and third trimesters until a small overall gain is established.
While many books caution that large women must gain at least 15 lbs.,
many women of size gain less and their babies are just fine.
Women who have recently lost a lot of weight or who are chronic dieters
often gain much more than 15 lbs. Although
the general goal for larger women is to aim for around 15 lbs., a gain smaller
or larger than this should not be a cause for great concern as long as baby is
growing well, nutrition is excellent, and all tests are fine.
Nutrition is the priority, not arbitrary weight gain guidelines.
Nutrition
for pregnant women of size is essentially the same as for every other pregnant
woman. Larger women may need
slightly fewer calories because they do not need to add the fat layer for energy
that smaller women need, but restricting calories can lead to complications and
has not been proven to be safe.
Emphasize
Proactive Behavior, But Don’t Lecture
Being
size-friendly doesn’t mean you shouldn’t help the woman to be proactive
about preventing complications.
On the contrary, this may be very helpful!
However, preventive advice should not be based on assumptions.
Take a careful history before jumping to conclusions, learn about your
client’s individual habits, and don’t make judgments before you know all the
facts. Base
your recommendations on a client’s actual history and habits, not on your
assumptions about them.
If
improvement is needed, please don’t lecture us.
Needing nutritional guidance is not unique to women of size---many
average-sized women have poor diets too!
Provide information non-judgmentally, and empower your client to help
make her own choices. Remember that many fat women come to you after years of
degrading treatment by medical professionals.
Choosing healthy habits of our own volition is much more empowering and
long-lasting than being shamed into them.
One
of the most powerful things you can do as a midwife is to emphasize your
expectation that all will be well, and to actively help your client to expect
that as well. Fat
women have had so much negative feedback that many have difficulty believing in
their body’s ability to work well.
Some may need help in learning to trust their bodies and feel comfortable
with them; active attention to emotional preparation for birth and working
through fears may be especially important for women of size.
Carefully
assess your client’s background; does she have issues of pregnancy loss,
fertility concerns, mistreatment by medical professionals, mistrust of
authority, body hate, eating disorders, or past abuse?
What are her fears about pregnancy, birth, and parenthood?
What are her hopes?
How does she see herself giving birth?
What kind of messages is she receiving from her friends and family about
this pregnancy?
Helping
a fat woman work through her fears and emotional issues is a very potent tool
towards helping her have a good birth experience.
A birth journal, birth art, visualizations, hypnotherapy, and guided
imagery are very powerful tools for change.
If you do not have enough time to address this adequately during
appointments, encourage the woman to see a therapist that specializes in birth
issues, or to take one of the childbirth education programs that emphasizes
emotional as well as physical preparation for birth.
Many fat women have reported this to be extremely useful, especially
after prior negative birth experiences.
Confer
with colleagues and share what you have found to work with larger women.
Online, midwives have reported great success in helping fat women birth
normally by helping them stay out of bed, to utilize lots of position changes
(especially hands and knees), to use birth balls, and to pay very close
attention to fetal position. Some
midwives report that using a Rebozo or other scarf tied around the middle may
help keep baby aligned better for birth if abdominal muscles tend to be lax.
Mobility in labor may be especially important for larger women.
If CPD is a concern, use positions that maximize gravity and pelvic
opening, and consider having the woman see a chiropractor to be sure the pelvis
(including the pubic symphysis area) is well-aligned.
Laboring in water and waterbirth may be particularly helpful too.
Discuss with other midwives what laboring
techniques or positions have worked well with women of size.
Ask your fat clients what is working best for them, too.
Trust that a fat woman’s body will tell her how she needs to labor,
just as any other woman’s body speaks during labor.
Empower her to listen to it and trust in it.
Help her to ‘go with the flow’ of what her body is telling her.
Treat
Us with Respect and Dignity
We
deserve the same respect that every other person gets.
That means treating us like equals and having respect for our
intelligence. It means not patronizing or condescending to us.
It means recognizing that many of us have a long history of negative
contact with health-care providers that we may need to overcome.
It means honoring our ability to make decisions for ourselves, even if
you do not agree with them.
It means understanding that WE are the ultimate authority on our bodies,
not you. As
one mother puts it, “[Show] respect for the individual person, regardless
of the body they wear.”
It
also means being honest about your own misgivings.
If you don’t think you can be size-friendly or if you have real
misgivings about possible complications or accommodations, be upfront with us.
Tell us honestly but respectfully what your concerns are, how you would
probably suggest handling things, and then let us decide if we can live
with that or not.
Treating
us with respect means looking for and seeing the beauty of our bodies---curves,
dimples, sags, folds and all. It means honoring our desires to become mothers
just like anyone else, and realizing that the ability to love and nurture, not
size, is the most important qualification for parenthood.
And it means respecting that the miraculous magic of making a baby can
happen in a lush body as well as a sparse one.
1
Crane, SS.
Association Between Pre-Pregnancy Obesity and the Risk of Cesarean
Section. Obstetrics and
Gynecology. February 1997. 89(2):213-6.
2
Michlin, R et al. Maternal
Obesity and Pregnancy Outcome. Israeli Medical Association Journal.
January 2000. 2(1):10-13.
4
Giacalone, PL et al. Delivery of
the Overweight Woman. Analysis of
115 Patients. Journal de
Gynecologie, Obstetrique et Biologie de la Reproduction (Paris).
1997. 26(3):288-92.
5
Leaphart, WL, et al. Labor Induction with a Prenatal Diagnosis of Fetal
Macrosomia. Journal of Maternal-Fetal
Medicine. March-April 1997. 6(2):99-102.
6
Combs, CA et al. Elective Induction versus Spontaneous Labor After
Sonographic Diagnosis of Fetal Macrosomia. Obstetrics and Gynecology. April
1993. 81(4):492-496.
8
D’Heureux-Jones, AM. Incision
Choice for Cesarean Delivery in Obese Patients:
Experience in a University Hospital.
American Journal of Obstetrics and Gynecology.
April 2001. 97(4):62S-63S.
9
Allaire, AD et al. Subcutaneous
Drain vs. Suture in Obese Women Undergoing Cesarean Delivery.
A Prospective, Randomized Trial.
Journal of Reproductive Medicine. April
2000. 45(4):327-31.
10
Naumann, RW et al. Subcutaneous Tissue Approximation in Relation to Wound
Disruption After Cesarean Delivery in Obese Women.
Obstetrics and Gynecology. March
1995. 85(3):412-6.
11
Perlow, JH and Morgan, MA. Massive
Maternal Obesity and Perioperative Cesarean Morbidity.
American Journal of Obstetrics and Gynecology. February 1994. 170(2):560-5.
12
Hellmuth, E et al. Oral
Hypoglycemic Agents in 118 Diabetic Pregnancies.
Diabetic Medicine. July
2000. 17(7):507-11.
13
Maxwell, MH et al. Error in Blood-Pressure Measurement Due to
Incorrect Cuff Size in Obese Patients. Lancet. July 3, 1982.
2(8288):33-6.
14
Cogswell, ME et al. Gestational
Weight Gain Among Average-Weight and Overweight Women---What Is Excessive?
American Journal of Obstetrics and Gynecology.
February 1995. 172(2 Pt.
1):705-12.
15 Bianco,
AT et al. Pregnancy Outcome and
Weight Gain Recommendations for the Morbidly Obese Woman.
Obstetrics and Gynecology. January
1998. 91(1):97-102.
Websites
Large Blood Pressure Cuffs
Amplestuff
There are 4 cuffs available. Economy Cuffs run between $30-40. Size L is for 13"-19" circumference arms, and size XL is for 17"-26" arms. Deluxe cuffs are more expensive but are tapered to fit better, have 'stays' to help keep shape on very large arms, and tend to be more comfortable for the super-sized. The Deluxe Cuffs come in size XL for arms from 17"-26" and size XXL, for arms from 23"-25".
Medical Supply Stores
Check your phone directory to see if there is a medical supply store in your area. They often carry (or are able to order) large blood pressure cuffs. There are a number of different sizes of cuffs, so be sure you ask about sizing.
Scales
Medical Supply and Scale Stores
These companies all carry counterweights that can be used on beam balance scales to extend a 350 lb. scale up to 450 lbs. Be sure to know what brand scale you have; you may need to order the exact kind that goes with that brand. Most counterweights run between $35-60 (averaging about $45), depending on the brand and the company.
Amplestuff
They have digital scales that go into supersizes, including some that go to 500+ lbs.
Large-Sized Gowns
Exami-Gowns
Sells hospital gowns, including special sizes. They have strong Velcro closures front and back, and generally come down to about mid-calf. Sizes up to at least 4x.
NAAFA Feminist SIG (Lynn Meletiche)
Will custom-make a hospital gown for you. Goes
well into supersizes. Call for details.
Copyright © 2002 Kmom@Vireday.com. All rights reserved. No portion of this work may be reproduced or sold, either by itself or as part of a larger work, without the express written permission of the author; this restriction covers all publication media, electrical, chemical, mechanical or other such as may arise over time.