Comment of the Week: Obesity is the Perfect Scapegoat

 

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By Jill—Unnecesarean

This comment was left by the Well-Rounded Mama on the post Obesity Causes a Rise in… Articles about the Cesarean Rate.

 

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 disproportionately 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 research 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.