Do Overweight Pregnant Women Need Separate High-Risk Hospitals?
This past Saturday, The New York Times published an article titled “Growing Obesity Increases Perils of Childbearing.” Moving right past the fact that the “perils of childbirth” are assumed, Hartocollis writes about the rising level of obesity and how this has affected obstetrics in the US. To illustrate the point, Hartocollis references the measures hospitals have had to take in order to account for this “burden in the maternity ward” and describes a premature birth (by Caesarean section) of a boy born to a mother who was estimated to be very obese when she became pregnant (either morbidly or extremely so, depending on whose terminology you use).
Ms. Garcia, the mother profiled by Hartocollis, had a BMI of 38 at the start of pregnancy and delivered her son 11 weeks premature after suffering from a number of complications described as “a constellation of illnesses related to her weight.” The chair of obstetrics of Maimonides, where Ms. Garcia delivered, is quoting as saying that doctors must weigh the risks of sections against the risks of vaginal deliveries in obese women. Maimonides is one of five hospitals in the New York City area now working together - with their malpractice insurer and a research group - to help figure out “the problem” of obesity during pregnancy. According to Dr. Adam Buckley of Beth Israel Hospital North, another center in the group, one solution might be to form hospitals designed specifically to handle obese women.
“The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean sections and intensive care for newborns,” Dr. Buckley is quoted in the article. These specialized centers would, presumably, solve some of the issues discussed in the article, such as obtaining sturdier examining tables and equipment and purchasing more precise fetal monitoring and diagnostic equipment. They would also have staff better trained to deal with variances in human anatomy, such as more adipose tissue that sometimes requires a different technique in procedures and anesthesia. At least one hospital in England has taken to this idea, requiring that women with BMIs of over 34 seek care approximately 20 miles away, in a better staffed maternity facility.
Hartocollis describes the sadness that Ms. Garcia felt, seeing her baby boy, born at less than 2 pounds, living in the NICU. She promises that she will go on a “strict, strict, strict diet,” promising her doctor that she will see her son graduate from college. While Ms. Garcia clearly has health problems to overcome - having suffered from kidney ailments and a stroke while pregnant - I am not convinced that specialized centers will solve “the obesity problem” in pregnancy, or even that the problem is even such as described.
To begin with, in the US obesity is described by BMI, or body-mass index. The equation used to determine BMI is:
BMI = [ (weight in pounds) / (height in inches)2 ] x 703.
Note that this equation *only* uses height and weight, period. There is no measurement for body fat, build, or athletic activity. As such, BMI is considered by many to be an inaccurate, at best, measurement of actual health. The Centers for Disease Control and Prevention states that BMI is not a diagnostic tool and that other measurements should be used to indicate health; BMI is simply a “screening tool.” The CDC also says that BMI measurements can vary in accuracy depending on age, race, and sex, and that measurements can be off for those more engaged in athletic activity, whose composition will likely be less fat and more muscle. An article recently published by the American College of Obstetricians and Gynecologists (ACOG) indicated that BMI measurements were also not as accurate as might be hoped in identifying obese women for counseling and risk purposes, although the article indicated that BMI missed more women than falsely included. The World Health Organization uses body fat measurements over BMI as a better indicator of health, preferring the precision and individuality of that measurement. However, body fat measurement requires more than merely a scale, tape measure, and calculator. Instead, body fat measurement requires calipers (and a well-trained provider), an immersion pool, or other inconvenient methods. Clearly, however, the measurements behind this push for specialized obese pregnancy centers are flawed in themselves, bringing into question the classifications for the higher risk and care.
Even assuming that the measurements for obesity are accurate, the question remains as to whether obese women - properly classified as such - need specialized care based on obesity alone. While obese women are at a higher risk for some complications of pregnancy, including hypertension, gestational diabetes, and pre-eclampsia, not all obese women will have these complications - and many “normal” or “overweight” woman will. If these centers become realities, will women be shuffled into them based merely on their BMI, or will some actual risk or complication have to become apparent before restricting places of birth? Already women describe being told in the first trimester that they will require a section, or that lower incisions don’t matter because clearly a larger woman does not care about her appearance and scarring, or that she is guaranteed to have gestational diabetes and a baby too large and unhealthy. These experiences, and the idea of specialized care centers based solely on a woman’s weight (without regard to actual risk and complications) are related more to size-phobia than to true care. Unfortunately, many people, including physicians, feel that women who are overweight or obese are lazy, do not care about their health, and “deserve” any complications coming to them. This is not a matter of needing specialized care in a segregated hospital, but needing providers who are aware of the potential special needs of an obese mother (or any mother), and who are not judgmental. All pregnant women should maintain an appropriate diet and level of activity, regardless of their BMI. Size-phobia, and related discrimination, can lead to poor care, assumptions, unnecessary interventions, and a C-section just as quickly as age- or race-related discrimination in obstetrics.
Finally, given the current crisis in maternity care in the US, what is the likelihood that these specialized centers or physicians will even offer the midwifery model of care, instead relying on frequent monitoring and additional testing (the cons of which are discussed on this blog and many others)? Given that counseling and support are recommended over diets, pills, and surgeries for encouraging healthy weight, how likely is it that women will receive such counseling and support when many OBs limit visits to fewer than 20 minutes? Will the classification of “obesity” require a specialist and yet more visits to health care providers during pregnancy? Will these specialized care centers also be equipped with a variety of less visible changes, such as blood pressure cuffs in various sizes, anesthesiologists capable of performing epidurals on women with more adipose tissue, and waiting room chairs designed for larger frames? Or will they simply be equipped with sturdier, and more plentiful, operating tables?