One of Janet Spinner’s patients with a 30-year-old woman who weighs 300 pounds. The woman had a miscarriage with her first baby. Then she had trouble getting pregnant again, so she had fertility treatments and conceived twins, who were born by Cesarean section. She subsequently had another baby by C-section.
Spinner (pictured), a nurse-midwife, has been seeing a trend firsthand: obesity leading to problem pregnancies.
Spinner estimated that almost 40 percent of her busy practice is made up of women who are overweight or obese (with a body mass index of over 30) or what used to be called “morbidly obese”—having a BMI over 40. BMI is a calculated relationship between height and weight.
Obesity increases the risk of needing to deliver a baby by Cesarean section. That in turn leads added risks from major surgery, potential for serious complications, and additional recovery time.
A recent flurry of news stories reported that the C-section rate in the U.S. has risen to 32 percent of all births—a 57 percent increase over the previous decade. Utah’s rate is the lowest at 22.2 percent; New Jersey’s is the highest at 38.3 percent. Connecticut ranks sixth at 34.6 percent and second in the increase—a whopping 75 percent—of such births from 1996 to 2007 (the latest year for which data is available).
The stories in the popular press, even a report from the federal Centers for Disease Control and Prevention, neglected to mention rising rates of obesity as a cause. Yet, doctors and midwives practicing in New Haven say data from their own field have confirmed the connection.
Stephen Thung has been practicing obstetrics with high-risk patients at Yale New Haven Hospital for the past five years.
“I spend most of my time with diabetic people—the rate is rising exponentially—and many are obese as well,” he said. “We know that diabetes is associated with higher risks of C-section, but obesity is recently a hot topic. People don’t think of obesity as an issue that needs to go to a high-risk obstetrician, but they do have many of the same risks.” He said a 2004 study published in the peer-reviewed American Journal of Obstetrics & Gynecology concluded, “Obesity is an independent risk factor for adverse obstetric outcome and is significantly associated with an increased Cesarean delivery rate.”
He said medical researchers aren’t sure why that’s the case. “The presumption is that their [obese women’s] labor is not as good; the vaginal tract may slow things down and make it more difficult to deliver vaginally, They also have other issues going on that make them not as good risks for vaginal births—weight gain is also associated with larger babies, and they may not come out smoothly. Sometimes the baby is injured.
A study published May 14 in the Journal of the American Medical Association shows that by 2000, 64.5 percent of all American adults were either overweight or obese. Other data show that there’s no significant racial or ethnic disparity among men, but among women the rate is highest for African Americans. More than half of black women 40 years and older were obese and more than 80 percent overweight.
Thung said the Institute of Medicine recently published maximum and minimum optimum weight gain for a successful pregnancy. “There used to be concern about not gaining enough weight—now we have the opposite problem. If your BMI is over 40 you may not need to gain any weight.” To illustrate, he gave sample BMIs for a woman of average height, 5 feet 5 inches: 200 pounds equates to a BMI of 33.3; 240 pounds to a BMI of 41; 300 pounds to a BMI of 50; and 500 pounds to a BMI of 80. “The BMIs that get us excited are 70 or 80,” he noted.
“People don’t talk about it [during pregnancy] because you can’t do much about it right there. You can’t ask them to actively diet, but after pregnancy you can counsel about weight loss, weight loss, weight loss.” He added that obesity can interfere with a woman’s ability to get pregnant because someone who is borderline diabetic doesn’t ovulate properly. Some women have gastric bypass or a lap band, which can aid in conceiving.
“Obese patients have no good options,” Thung concluded. If they can’t deliver vaginally, they are at increased risk of complications from a C-section, such as clotting in the legs associated with a pulmonary embolism, and increased risk of wound breakdown.
He said the National Institutes of Health recently invited him to participate in a working group on the link between obesity and cesarean sections.
“Obesity decreases fertility and increases the chance of losing the baby, of hypertension and pre-eclampsia, which kills a lot of women around the world,” said midwife Spinner. And because fertility drops with rising obesity, many women seek help in conceiving from fertility treatments, which increases the chance of having multiples (twins and triplets) and therefore increases the chance of having a C-section.
Obesity is a risk factor in C-sections independent of other factors, but it goes hand in hand with other serious complications, like diabetes and cardiovascular disease. Spinner said another reason that obesity increases the C-section rate is that in very heavy women, it’s often difficult to accurately assess the size of the fetus, leading many obstetricians to play it safe by doing the surgery, rather than attempting a vaginal birth. Another reason: When a woman is severely obese, her fat impinges on the birth canal and vagina, possibly endangering the baby during a normal delivery, so docs often opt for a C-section.
Spinner said reducing weight gain in pregnancy is one of the more “modifiable risk factors.” Not that it’s easy. She sees modern American culture aligned against the best possible outcomes for pregnant women—from the easy availability of high-fat, high-salt, high-sugar junk foods (and the corresponding dearth of healthy foods in poor neighborhoods) to the couch potato culture, the cutbacks in sports programs for youth and the lack of safe places for many youngsters to play, forcing many into a sedentary lifestyle.
Spinner said, ideally, obese women should lose weight before becoming pregnant, with a BMI down to 23 or 24. .A “normal” BMI ranges between 18.5 and 24.9. Click here to determine your own.
The client mentioned at the top of the story above had reached Category 3 obesity—a BMI over 40. “It’s so embarrassing [to be obese] and such hard work [losing weight] that people are in denial,” Spinner said. But she added that this patient had finally recognized she had a problem, and wants to take action. She’s going to try Weight Watchers, which has helped many people lose weight and keep it off with a combination of flexibility in food choices and social supports.
Both Spinner and Thung said a major cultural shift is necessary in order to significantly reverse the obesity epidemic, and with it the rising C-section rate. Short of that, Spinner said, her patients will have a tough (and fat-, sugar- and salt-filled) row to hoe.
posted by: Morris Cove Mom on May 18, 2010 2:26pm
And they wonder why malpractice rates continue to soar, and doctors are forced to retire young to avoid crazy lawsuits and insurance premiums!
More accountability should be taken by the mothers and mothers-to-be, not by the providers.
“almost 40 percent of her busy practice is made up of women who are obese” is insane to hear. This patient also sought fertility treatments, which cost $15,000+ per treatment. But there is no mention of nutrition counseling, diet, or exercise. Why are people desperate to have children when they cannot even take proper care of themselves?
Janet Spinner is a class act. She delivered my younger daughter, while being my midwife, cheerleader, and therapist simultaneously. It was not an easy birth for me, but I did not need a C-section, I am always proud to say…as I am a healthy weight, and work to learn more about nutrition, diet, and exercise. For me, my husband, and my two children.
posted by: Jonathan Hopkins on May 18, 2010 4:13pm
Morris Cove Mom,
We federally subsidize corn to the point where corn products can be found in most of the food in grocery stores. It’s cheapness allows it to be manipulated in labs and turned into all different (‘different’ is a relative term) foods that are over overwhelmingly fatty and generally unhealthy, but it is also the cheapest stuff in the stores.
For over a half century, we have become dependent upon industrial scale farming that produces extremely unhealthy, meats and crops. Agriculture has been replaced with efficiency-based food manufacturing. We over produce our land to the point that it becomes dry and completely nutrient bare, which is why we have to pour petroleum based products on it to grow anything. We’ve replaced real food with look-alike dye filled, chemical-rich pseudo-foods.
We also have invested most of our nations wealth into a living arrangement that requires driving everywhere for everything because of nonsensical zoning and codes. We shell out $300 billion worth of our ancestors hard work to the middle east just for us to have the privilege of living in environments that are filled with pollution, noise, and dangerous conditions.
The country is designed for only half the population-the people who are physically able to drive and can afford a vehicle for every adult. The other half are relegated to the public realm where the health benefits of walking are overcome by horrible air quality, speeding cars and extremely ugly and unbearable environments that make walking unpleasant or flat out impossible.
To make things better, what was great local farm land has now mostly been replaced with low-density housing, strip malls, office parks and car infrastructure, which only continues to consolidate our productive land to industrial farms in the mid west.
Anyone’s sense of personal responsibility and will to act on those perceived responsibilities has been massively destroyed by the systems that we’ve created and since become dependent upon. Unfortunately, our only solutions to these obvious problems seem to be to demand that people become more “responsible” and buy food they can’t afford (?) or wait for the pharmaceutical industry to develop another diet pill.
All we have to do is distribute the farming subsidies amongst many crops and amongst localized farms, in which case the inherent inefficiencies in local farming (as compared to industrial scale farming) is offset by the resulting cost savings in health care. Local farming also demands that many suburbs be reorganized to make way for farms and in this reorganization, walkable communities can be established that would be able to support transit, thus solving each problem I mentioned above.
posted by: Meat on May 18, 2010 4:31pm
The “meat” of today isn’t the “meat” your grandparents ate. It’s sold pre-packaged, irradiated, and often is infected with bacteria.
The meat of today also is responsible for incredible water pollution, biodiversity in feedstocks, and unimaginable suffering. Not only animal suffering, but suffering of those who are forced to slit throats of live animals, break beaks off baby chickens, and throw male chicks into a grinding machine *alive* because male chickens are “of no use” to the industry. If you think our soldiers have it bad with PTSD, I wonder what the workers at factory “farms” have to deal with?
The solution to our obesity epidemic is simple: Cut the meat. Eliminate an industry which depends upon cruelty & exploitation and instead embrace the kindness & wholesomeness of a plant-based diet.
I lost 20 pounds since thanksgiving 2009- by eating a vegan diet. I went to the library, got some cookbooks, and (thanks to the recession) EBT card in hand, I bought some fresh produce. I’m a college graduate, am receiving emergency food stamps, and can certainly afford the produce (from Edge of the Woods, across the street from shuttered Shaws!) necessary for my health.
What we need isn’t to complain about obesity or it’s causes, what we need is NUTRITION CLASSES IN SCHOOLS. Focus less on fractions and more on the basic need of humans- FOOD.
It’s sad when I hear the statistic that today’s youth will NOT outlive their parents. Overweight? Don’t wait- reduce your fatty foods (MEAT), and increase your grains, fruits, and veggies! Your healthcare costs will be lower, you will be more attractive to your partner (or potential partners), and you will be able to get out of a burning building through a partially-opened door.
Think of the EMT’s who will have to carry your large self down those 3 flights of stairs if you fall in your apartment. If you can’t do it for yourself, eat better for those who will be taking care of you! No meat!
posted by: Jonathan Hopkins on May 18, 2010 9:46pm
I mostly agree with your post, but I think nutrition education is ultimately unnecessary-in the same way that exercise education is unnecessary. It should unquestionably be a right that every child in this country have safe transportation options from walking to biking to transit, as well as access to affordable fresh produce and meats. We need to reform meat production and rediscover agriculture through diversified subsidizing (in terms of types of produce and location in the country), as well as the reorganization of our living arrangement to make in possible for local agriculture to be the primary supplier of our country’s food and to create more healthy environments that encourage naturally-occurring daily exercise as part of the average life.
I am aware of the horrible meat production process in this country, but I think it is appropriate to separate that from traditional livestock raising. My grandmother, for example,used to raise chickens to be used for eggs and eventually their meat, which she personally prepared at her home. I think we definitely need to cut down on our meat consumption (meat as part of 2-3 meals per day is absurd), and also diversify the types of meat eaten from fish to poultry to beef. I personally rarely eat beef because its too tough and does a number on my stomach trying to digest the dense muscular tissues, but I don’t think its evil for people to eat beef moderately, so long as we return to a relatively more humane and local relationship to meat production.