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Thursday
Aug192010

Obesity Causes a Rise in… Articles about the Cesarean Rate

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By Jill—Unnecesarean


 

 

If the cesarean rate goes down to the mid-20’s over the next ten years, who will be the first to offer up their expert opinion to the press and inspire titles like “Cesarean Rate Down, Fewer U.S. Women May Be Obese” in newspapers?

The problem with many articles in which an expert attributes the high cesarean rate to rising obesity rates is that they are written with an obvious anchoring bias that these cesareans were all necessary (due to a complication of obesity) because they were performed and that they would not been performed had they not been necessary. It’s the argumentum ad necesarean.

Except for the article in the New York Times in June 2010 which said something original about a consortium’s plans to build a separate hospital for obese pregnant women, most articles about obesity and cesareans tell the reader nothing more than doctors are more likely to perform a cesarean on obese women.

Saying that doctors are more likely to perform a cesarean on an obese women tells readers that doctors are more likely to perform a cesarean on an obese women. Period.

My point is not that obesity has no effect on the likelihood that a cesarean will be needed to prevent injury or death to mother or baby. My point is that the majority of articles written trying to link the rise in obesity to the rise in the cesarean rate tell us nothing more than an article linking the rise in the cesarean rate to the rise in housing prices.

The Well-Rounded Mama wrote about some of the actual risks associated with obesity and pregnancy in her post, Exaggerating the Risks Again:

For example, Weiss (AJOG, 2004), a large study of more than 16,000 women in multiple hospital centers, found that 9.5% of “morbidly obese” women (BMI more than 35) experienced Gestational Diabetes during their study.  The number certainly is higher than the 2.3% with a BMI less than 30, so it is definitely a risk (4x the risk—-gasp!) that should be communicated to women of size.  

However, it also means that 90% of “morbidly obese” women did not develop Gestational Diabetes.  So while the risk increased, it should be remembered that the vast majority of morbidly obese women will not get GD.  

Pre-eclampsia is another risk that is substantially increased in “obese” women, and this one can be life-threatening to both mother and baby.  It is definitely a risk that must be discussed as a possibility and taken very seriously.  But in the Weiss study, only 6.3% of “morbidly obese” women developed Pre-eclampsia….higher than the 2.1% of non-obese women (3.3x the risk—-gasp!) who developed PE, but hardly universal.  Remember, 93% of “morbidly obese” women did not develop Pre-eclampsia in that study.  

Again, the majority of these women did not get GD or PE, the two most common risks for women of size.

So while these risks are real and it’s only sensible that the possibility be discussed with women of size (and that women of size be proactive about lessening their risk for them), it’s important that the magnitude of the risks not be exaggerated or to imply that such a complication is virtually inevitable. 

 

If you’re a journalist and you’re going to interview an expert on the correlation between obesity and cesarean sections, don’t just settle for something like, “I perform more cesareans on obese patients; therefore, I deem them to be necessary.” Please get percentages and citations. If they don’t want to or can’t give you any numbers, that’s your story.

 

 

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Reader Comments (10)

As a doula, educator and mom I stress critical thinking and empowerment through knowledge. I am so thankful to be a member of a community that reminds me to follow my own advice.

August 19, 2010 | Unregistered CommenterShannon

I love it. This is a great response to all the articles just like that. While I suppose it could be true that obese (personally as a morbidly obese person, I prefer the word fat, but I understand why you used obese) women MAY need a c-section at a slightly higher rate than non-obese women, these quotes show nothing.

I honestly think that the fact is that most doctors have no idea and they are just worried about complications so they are more likely to do a c-section. So really, I would guess that unnecesareans are more common for fat women simply because they are fat.

As purely anecdotal evidence, I had two pretty healthy pregnancies and two vaginal births, one of which was at home. I did not develop GD, pre-eclampsia, hypertension or any other complication that could have been associated with my weight.

August 19, 2010 | Unregistered Commentercraphead

Trust me, performing a cesarean on an obese woman is NOT what anyone wants to do. The surgery is more difficult and the risk of complications is higher.

August 19, 2010 | Unregistered CommenterPam

I hope you are right, Pam. I do think it is important for fat women to be informed and to try to have a very healthy pregnancy in order to avoid c-sections (but I'm sure we could easily make that argument for ALL pregnant women, not just fat ones). But it's also a good idea for doctors and staff to get over preconceived notions and give a fat mom a chance to have a healthy pregnancy and a vaginal birth.

I went running (and crying) from my first OB visit. I had just gotten some bad news and was very upset and nervous when I got there. I was feeling flushed and I told them that. Still, they took my blood pressure and I guess it was very high. I explained to the OB several times that my blood pressure had NEVER been a problem and that I was sure it was a fluke. He started talking about sending me to a perinatologist (isn't that what the high risk OBs are called?). Anyway, after refusing to look at me or talk to me (only to my husband), not listening, and scaring the crap out of me, as well as not letting me change into clothes after the exam (and before he talked to me), I decided he was an SOB. I wrote a letter to the office complaining about all that and sought care elsewhere, with midwives. I believe that sort of treatment would NOT have happened if I were thin and that if I had stayed in his care I would have ended up having a c-section.

August 19, 2010 | Unregistered Commentercraphead

craphead (best name ever, btw), the linked post about building separate hospitals for "obese" women covers some of the labeling issues. Who is really obese? Who is really morbidly obese? What is the cut-off and are we just going by the BMI without looking at any other factors?

Thanks for your comment.

August 19, 2010 | Registered CommenterJill

My mother called me about one of these, all frantic that I was putting myself and my baby at risk by choosing to birth at a birth center. (I am fat.) Fortunately, I'd read the paper the article was based on, and I was able to demonstrate to her that 1) my midwives are MORE vigilant than my OB was about detecting GDM and PE and 2) while there is a correlation between BMI and C-section rate, there is NOT a correlation between BMI and *necessary* C-section rate. Since I was able to cite and show numerous factors that would cause conventional care to move faster to a section in a fat woman than a skinny one (lack of good response from continuous fetal monitoring, difficulty repositioning an epiduralized fat patient, &c) she calmed down and accepted that my decision to birth in a birth center rather than a hospital was probably a GOOD one for me and my baby!

August 19, 2010 | Unregistered CommenterKathryn T.

When you've got a hammer, everything looks like a nail.

1. OMG breech! Better have a c/section!
2. OMG twins! Better have a c/section!
2. OMG obesity! Better have a c/section!
3. OMG you've labored slightly longer than the extremely short and outdated timeline we set up! Better have a c/section!

Just like in Sunday School, when the answer was always "God" or "Jesus", in obstetrics, the answer to any question is always "C/section!"

What I have especially *never* understood about obesity = c/section is that any abdominal surgery is *more complicated* on an obese person--the extra tissue makes reaching and operating on the organs that much harder, and thus presumably, more prone to complications. I have read doctors complaining about this, when talking about appendectomies, etc.

Whereas no matter how obese you are, your vagina stays free and clear, no? So wouldn't you want to encourage obese women to have a *vaginal* birth, as a matter of safety?

I have yet to get a good answer to that question, which does nothing to decrease my cynicism on this topic.

August 20, 2010 | Unregistered Commenteremjaybee

Dear Kathryn, I am an OB/GYN and I understand why this seems to be contradictory. However, an emergency or unplanned c-section on an obese woman is more risky than a planned c-section. One reason is that it takes longer to provide anesthesia safely. Also studies show that prolonged labor is more likely if a woman is obese, partly because obese women have larger babies. While the higher rates of c-section among obese women may be partly due to doctors viewing heavier women as "high-risk" and throwing in the towel sooner, it may also be because obese women are more likely to have a longer labor that then leads to an abnormal fetal heart rate tracing, or the labor not progressing. Doctors also want to avoid the emergency c-section (the kind where you have to get the baby out in minutes), because of the anesthesia risks and also because it takes longer to get the baby out if the woman is very obese. But I agree also with the earlier post that most obese women can have a normal pregnancy and birth. Midwives are much better (in general) than OBs at helping women achieve a normal delivery, whatever their size - that's why I had my babies with a midwife in attendance.

August 21, 2010 | Unregistered CommenterNaomi Stotland

Naomi, thanks for your comment. In just a few sentences, you told us more specifics about possible risks associated with obesity and pregnancy than almost every news article about obesity and cesarean rates I've read.

August 22, 2010 | Registered CommenterJill

One of the things these articles rarely note is that "obese" women are induced at mind-bogglingly high rates, usually for "suspected macrosomia" or for "postdates" but sometimes also just because the docs believe that fat women don't go into labor on their own or are too high-risk to contemplate going longer.

We know from other research that induction STRONGLY raises the risk for cesarean, especially in first-time moms, in moms with suspected macrosomia, etc. Why then, does no one in the obstetric field or the media connect the dots? If fat women are being induced at numbingly high rates, then it is surely no surprise that they have a higher cesarean rate. The problem is that no one in the obstetric field wants to look at the IATROGENIC influences on the cesarean rate in women of size. Thus, no one ever questions the high rates of induction in women of size nor questions whether reducing inductions might reduce their cesarean rate too.

If you look back at the historic literature on obesity and pregnancy, you often find that the cesarean rate was NOT higher in women of size, or only slightly higher. Certainly not the sky-high rates it is now. Cesarean rates have increased in all women, it's true, but much more disproprotionately in women of size.

I believe this is because of the way that fat women's pregnancies are managed now, with high rates of induction, strongly encouraged early epidurals, restricted mobility in labor, and a very low threshold for surgery etc. Also, many doctors don't realize that fat women tend to have longer menstrual cycles and so don't adjust their due dates accordingly, making for more "postdates" inductions. And finally, there is an exaggerated sense of risk now around obesity in pregnancy, with doctors increasingly adopting "scorched earth" tactics and extreme protocols for women of size. Thus the push for specialized centers for fat pregnant women, in effect ghetto-izing them to high intervention and high-risk management.

None of this is to say that there aren't possible and real concerns about pregnancy in women of size. Of course there are, and a higher rate of pre-eclampsia and GD is going to lead to some of those inductions....but the majority of those inductions are pre-emptory, not based on actual complications. And proactive prevention via the midwifery model of care goes a long way to reducing these problems and giving a greater chance for a normal pregnancy and normal vaginal birth. The fat women I know who go the high-tech, high-intervention route end up with a LOT more cesareans than the fat women I know who go the low-tech midwifery model route. It doesn't prevent all problems, of course, but it does help a LOT. But increasingly, fat women are being socialized away from or even legally KEPT from access to the midwifery model of care.

I have written many times about the cesarean rate in women of size, why it is so high, and what women (and providers) can do to lower the rate. You can read more about this (with reseach citations) in the article I wrote for Our Bodies, Ourselves at:

http://www.ourbodiesourselves.org/book/companion.asp?id=21&compID=125

The bottom line is that doctors are human. They don't like to acknowledge that they (and the way they practice) are part of the reason why the cesarean rate is rising so strongly. So they look for other, outside factors to blame. For a while it was all the women "choosing" elective cesareans. Or women delaying childbearing. Or the increase in multiples from fertility treatment.

One of the reasons that gets the least pushback is the obesity epidemic. It's the perfect scapegoat, because it's everyone's favorite target and rarely is it questioned, even among many natural childbirth advocates. Critical thinking does not get applied to the research, and no one questions conclusions....like all those cesareans being performed on fat women MUST have been necessary ones. So my prediction is that we'll see a lot more of these stories in the future.

Just keep in mind that when you see a story like this, you are seeing a masterful blame deflection job. Yes, there are real questions and concerns to address about "obesity" and pregnancy, but beware of letting it be blamed for the cesarean epidemic in the country. The story is far more complex than that....but rarely is it presented so.

August 22, 2010 | Unregistered CommenterWellroundedmama
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