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Tuesday
May172011

Should Providers Refuse to Treat Overweight Pregnant Women?

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By ANaturalAdvocate

Various media sources (including social media) have been abuzztoday regarding news of some ob-gyns in Florida refusing treatment to some patients on the basis of weight/BMI alone. The Baltimore Sun article on this practice is one of the more detailed pieces to come out; please read the original article here, as only portions will be dealt with here. 

Now, for the “fisking.”

In a nation with 93 million obese people, a few ob-gyn doctors in South Florida now refuse to see otherwise healthy women solely because they are overweight.

It is important to keep in mind that these women are being denied care *solely* as a result of being obese/overweight, before developing any particular complications related (or not!) to their weight.

Fifteen obstetrics-gynecology practices out of 105 polled by the Sun Sentinel said they have set weight cut-offs for new patients starting at 200 pounds or based on measures of obesity — and turn down women who are heavier.

While this isn’t a terribly scientific method of inquiry, it’s still over 10% of the area ob-gyns interviewed who felt it necessary to develop weight guidelines for accepting patients. It is unclear here whether the women are denied care if they are/were above the guidelines before pregnancy or if they reach them during pregnancy as well. A cutoff of 200 lbs. could impact a number of women, both before and during pregnancy, particularly women who already tend towards that end/are taller/athletes/etc. It is also unclear how “obesity” is measured, although it is assumed that the ob-gyns use BMI to determine whether a woman should be denied care. The problems with BMI (and pregnancy) have been dealt with here, as well as at The Well-Rounded Mama and a number of other blogs. 

“People don’t realize the risk we’re taking by taking care of these patients,” said Dr. Albert Triana, whose two-physician practice in South Miami declines patients classified as obese. “There’s more risk of something going wrong and more risk of getting sued. Everything is more complicated with an obese patient in GYN surgeries and in [pregnancies].”

People don’t realize the risk we’re taking by taking care of these patients.” Would these people be the pregnant women, taking their own risks in pregnancy and childbirth? And why are the risks of the situation focused on the physicians, and not the patient? If the reason that these ob-gyns are turning down patients due to weight is because of complications, why not deal with that? Ah…”more risk of getting sued.” Dr. Triana’s practice also declines “obese” patients, which can range from a very unhealthy person prone to complications to, say, an athlete.

Plantation ob-gyn partners Jeffrey Solomon and Isabel Otero-Echandi turn down any woman weighing more than 250 pounds.

Solomon and Otero don’t want to begin seeing heavy women and then have to send them to specialists if they later develop problems, said their office manager, who asked not to be named. The two doctors, like several of the others with weight cutoffs, declined to comment.

These two physicians do not want to later have to refer women out; what do they do with patients who develop actual complications later in pregnancy? One presumes that they refer them out to the needed specialists. 

“This is not a high-risk practice,” the office manager said. “They are not experts in obesity.”

If the ob-gyn’s office is not high-risk, whom is it designed to handle? In addition, is there a specialty in pregnancies of obese women? If not, then to whom are these women being referred, since the regular ob-gyns - the people trained to assist in higher-risk births - are refusing to see them? The hospital the practice refers to had, in 2008, a Cesarean section rate of 46.7%, significantly above the state average. 

Turning down overweight people is not illegal for doctors, but the policy worried leaders of physician groups, medical ethics experts and advocates for the obese, all of whom said it violates the spirit of the medical profession.

While it is completely understandable to refer patients out if a practice if unable to take care of them, it is something else entirely to deny women care simply because they might possibly have complications at some point. 

So far, the weight cutoffs have been enacted only by South Florida ob-gyns, who have long complained of high numbers of lawsuits after difficult births and high rates for medical-malpractice insurance. More than half go without coverage.

It is interesting that an area decried by the doctors as having a high rate of lawsuits, and where many of the doctors do not carry malpractice insurance (!!!) is one of the same areas where women are constantly faced with a lack of choice around pregnancy and birth. 

Several ob-gyn offices said their ultrasound machines do not give good images of internal anatomy in obese women, making it harder to diagnose medical problems. 

A lack of appropriate equipment is an understandable reason to refer someone out - for that procedure, much like patients are referred out for x-rays, CT scans, and even ultrasounds during pregnancy, as many offices only maintain older or more basic equipment in office, referring out for detailed images. 

The Plantation office manager said weight limits are not uncommon at offices owned, like hers, by the Coconut Grove medical services company VitalMD.

VitalMD Group Holding, LLC describes itself as “a large group practice focused on delivering high-quality women’s health care. Founded by an expert team of savvy physicians and business professionals, VitalMD was formed to help its physician members achieve their financial, operational and clinical goals through the group practice model while allowing them to refocus their time on providing quality patient care.”

VitalMD treasurer Kerry Kuhn, an ob-gyn in Coral Springs, said he was unaware of his doctors setting weight limits, adding the company has nothing to do with doctor decisions.

“This is individual choice by a doctor,” Kuhn said. “Doctors know who they want to treat.”

Doctors. know. who. they. want. to. treat. 

Doctors also are allowed to drop patients, if they believe they lack the medical skills to properly treat them. They must send notices and refer them to other doctors.

If this significant a proportion of physicians are unable to properly treat obese/overweight patients, it begs the question as to why these professionals are not trained to treat these patients. 

But decisions about patients typically are made after assessing the individual’s condition during an exam, not by ruling out an entire group, said Dr. Robert Yelverton, a board member of the Florida Obstetric and Gynecologic Society. He said he would discourage physicians from excluding the obese.

“Do I think it’s a good policy? No,” Yelverton said. “Overweight people need doctors. I don’t know where a patient in that situation would go if every practice had that policy.”

———————————

Do you know of any physicians/midwives who use the same or similar criteria in accepting patients for care? Have you been denied care as a result of your weight or BMI? Are you a provider who denies care to patients not meeting certain weight/fitness guidelines? 


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Reader Comments (35)

See also this post on the First, Do No Harm blog, about a fat woman whose anesthesiologist during a D&C to complete a miscarriage tried to sell her weight loss surgery: http://fathealth.wordpress.com/2011/05/16/miscarriage-d-c-scheduled-doctor-suggests-wls/.

Quite frankly, one of the reason I chose home birth was that it gave me more control over who attended my birth, and I could make sure beforehand that person would not be fat phobic. It worked great, btw - best midwives ever! I was also fortunate in that my one miscarriage was complete at home, or I might easily have found myself in the same scenario as the woman above.

Perhaps you've all noticed that one reason physicians frequently give for the rising c-section rate is that more women are fat, and thus require more interventions. Well-Rounded Mama calls this out for the unscientific assertion it is in at least one of her excellent posts, but to my mind, it's more a convenient way for physicians to blame women rather than examine where the problem really lies. I have no doubt physicians honestly believe that fat women are inherently unhealthy; physicians live in the culture, just like everyone else, and are hardly immune from its prejudices.

May 18, 2011 | Unregistered Commenternaomi

I am an obstetrical care provider who has never denied care to anyone. I am a doctor first and a private business second. Or in other words, I have a private business that allows me to be a doctor. I didn't go to business school, I went to medical school.

I am happy to report that I do not know of any OB practices in my area that impose "weight restrictions" and frankly I find it repulsive that anyone who calls themselves a doctor would deny care because a patient is overweight.

I think that a “doctor” who denies care based on risk should consider becoming an insurance salesman.

Apparently in that part of Florida, malpractice insurance is untenably expensive: http://findarticles.com/p/articles/mi_m0843/is_2_28/ai_84236557/

There are physicians out there who don't *make* that much in a year.

May 18, 2011 | Unregistered Commenterjodie

I'm a very plus-size woman, I've had three children, and the only concerns my ob's ever had in regard to my weight was:
1. risk of high blood pressure
2. risk of gestational diabetes
3. getting just the right cut & close on my very necessary c-sections.

That's IT and that's ALL. I had multiple ultrasounds will all my children, and I never ever had a tech claim they couldn't get a good picture because of my weight. A couple parts were a little tricky, but a well-trained tech can still make it happen.

If anyone in the metro Detroit area is reading this and looking for a pro-woman ob-gyn, check out Mission Ob-Gyn in Warren, MI. They're on 13 Mile near Hoover, and it's an all-female practice. The doctors, nurses, office staff, etc. are all women. It's a VERY comfortable environment.

May 18, 2011 | Unregistered CommenterM.

The CNM-run birth center in my city lists these weight criteria among a whole host of things that would preclude someone from having a birth center birth. They are willing to provide prenatal care, but consider these "moderate risk" (according to their website) and more appropriate for a hospital birth. A woman who has had gastric bypass surgery also cannot give birth there. Nor can a woman with active anorexia or bulimia within the last year.

• Primip (first time mom) BMI 35 and higher
• Multip (mom with at least one child) BMI 40 and higher
• BMI of less than 17.5 (primip or multip)

This seems less restrictive than these OBs, but I don't know what, exactly, they are basing it on. Some of the other things on the list - breech, VBAC, twins - they are prevented from handling due to state law. Yet other things - smoking after 12 weeks, past 20 weeks with no prenatal care - are judgment calls.

Whether they are justified or not in having these restrictions, it seems particularly weird for OBs to exclude obese women. OBs are for "high-risk" or "moderate risk" or whatever patients.

May 18, 2011 | Unregistered Commentererica

This is unethical.

Of course, they (doctors) do a lot of unethical things.

This does not surprise me, but it does make me wonder what is next for some physicians.

Fat-phobia to the point of refusing the patients is almost to the patients benefit: they won't be auto-sectioned by THEIR obviously inexperienced with obese (by their own choice, apparently) patients scalpel. Just like the docs that refuse patients with doulas, birth plans, etc.

However, obese women.. unfortunately.. they'll probably be near auto-induced and likely sectioned by someone else who is also fat-phobic but has (perhaps only slightly) better ethics but just as few minutes and just as high malpractice rates.. At least there are some docs on the side of birth plans and doulas.. but are there many on larger women's side? I doubt it. That is unfortunate, too, since things do not usually have to be this way.. and part of it goes back to the last post that was made. If doctors didn't have to shell out so much for damaged humans, would some be so restrictive about which ones they "let" into their offices? Maybe not. But, is it still unethical? Yeah.

May 19, 2011 | Unregistered CommenterFogedaboudid

I see zero problem with this. I am reading a lot of comments in here from many of you that are in total denial that you are obese. If you're over 250 and nothing short of 6'0 and male - you are obese! It is an epidemic in this country and we need to be held accountable to lose weight!!!

We really do want it all in America dont we? We want to eat what we want when we want, and yet not be called out for being overweight - and then not have our insuranance premiums go up at ALL because we ARE overweight - and yet should a problem happen that was brought on by our poor health we immediately want to sue the doctor... can we say vicious cycle here anyone?

Doctors are getting fed up. Insurance is paying them less and less and their malpractice insurance is skyrocketing, and no one is looking out for them so they're looking out for themselves.

I'm laughing at the previous poster that says the ONLY problems she presented to her doctor were
1. risk of high blood pressure
2. risk of gestational diabetes
3. getting just the right cut & close on my very necessary c-sections

um these are VERY HIGH RISKS!! and can be deadly!! to toss them out there like it's no big deal is just laughable. No one is talking about someone who is just a few pounds 'fluffy' here. The term is OBESE.

May 19, 2011 | Unregistered CommenterNo issues

But if OB won't see you, who are you supposed to go to? I understand obesity involves increased risks, but if someone who is supposed to be a specialist in the area of pregnant women won't see you, that is not right.

May 19, 2011 | Unregistered CommenterSteph G.

I was overweight (technically obese at 30 BMI) when I conceived my third child, and just over 200 lbs (I'm tall). I did not intend to get pregnant when that overweight, but I immediately dealt with it responsibly. I was in my late 20s and healthy (other than being overweight). I started working out with a personal trainer 2x/wk, regularly attended prenatal yoga/pilates and other classes, and ate very carefully. I lost almost 15 lbs in the first trimester, and then slowly gained from that point forward, to a total of about 220 lbs at delivery. I had a spontaneous and precipitous labor at just past 40 weeks gestation, a planned home birth that my midwife was unable to get to in time because the birth was so fast (less than 2.5 hours total; only about an hour from being sure I was in labor to baby arriving).

The entire pregnancy was healthy, I was healthy, baby was healthy, and there were no medical complications whatsoever at any time. In fact, I was so strong from all of the exercise/personal training I was getting (which I continued until the day I gave birth) that I was easily able to labor and give birth in an upright position without assistance other than someone to hold my hand during contractions.

I understand where the physicians are coming from, but I think it makes more sense and is more in the spirit of the medical profession and oath to counsel women on responsible behavior during pregnancy to manage the complications and risks that can arise with obesity and pregnancy, and to transfer a patient when necessary, than to reject all women who do not meet a specific weight criteria. I knew that getting pregnant at the weight I was at was not ideal. I was concerned about possible issues like high blood pressure or GD (neither of which occurred). I made a concerted effort to take very good care of myself and understood that complications of pregnancy (perhaps due to or related to obesity) could risk me out of the midwife's practice/home birth, but it would have been a shame if my provider had refused me care simply because I started the pregnancy over 200 lbs.

FWIW, I had had two prior uncomplicated, unmedicated vaginal births at a lower pre-pregnancy weight but similar delivery weight.

May 19, 2011 | Unregistered CommenterAnonymous

I don't mind a doctor being able to choose his patients. I think not choosing someone who is overweight is ridiculous though. There are women out there that have far worse problems than that, though. I mean isn't that why they decided to become a doctor. To help in high risk pregnancies?

May 19, 2011 | Unregistered CommenterRachel
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