Much has been written about the alarming increase in the percentage of births delivered via cesarean section. Our Bodies Ourselves has just posted a new article that discusses the sky-high rate of cesarean births among women of size and provides concrete advice on how women can best increase their chances of having a vaginal birth.
The author, Pamela Vireday, a childbirth educator and size-acceptance activist who specializes in summarizing and analyzing the medical research on these issues, spoke with Our Bodies Ourselves recently about the abundance of misinformation and attitudes toward women and obesity.
“A cesarean can be a wonderful and life-saving thing when it is needed, but to use it routinely adds many unnecessary risks, especially in obese women,” says Vireday. “Yet almost no one has been questioning the high cesarean rate in this group, or looking for ways to lower the cesarean rate.”
Read the full interview below.
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Our Bodies Ourselves (OBOS): Why did you write this article?
Pamela Vireday: I wrote this story because I am outraged that no one is questioning the high cesarean rate in women of size today. The first-time c-section rate is nearly 50 percent in “morbidly obese” women in many places. Between first-time cesareans and automatic repeat cesareans, probably more than two-thirds of all women of size will have their babies surgically removed in some places in the country — and many of these are unnecessary.
A cesarean can be a wonderful and life-saving thing when it is needed, but to use it routinely adds many unnecessary risks, especially in obese women. Yet almost no one has been questioning the high cesarean rate in this group, or looking for ways to lower the cesarean rate. I find this unacceptable.
There needs to be real dialogue about this issue, more than just the usual mantra of “lose weight.” Research shows that permanent weight loss is very difficult to achieve, and only a very few lose weight and keep it off for very long.
The reality of the situation is that many women will have pregnancies while obese, and we need to know how best to serve these women, to make their pregnancies and births as empowering and healthy as possible. Having unnecessary surgery is a difficult way to begin motherhood.
OBOS: How did your own experiences influence this article?
PV: I also wrote this article because of my own journey. I have four children, the first two born by cesarean and the second two born by VBAC (vaginal birth after cesarean).
My first cesarean was the result of being pressured into every intervention known to doctors. Only later did I find out that many of their recommendations were unnecessary and even risky. I certainly was not given good informed consent about the pros and cons of these interventions. It was not even presented as a choice.
Over time, I began asking questions, reading the research, and becoming a partner in my own care. I questioned the doctors’ assumptions about obesity and how that influenced their recommendations. They meant well, but their own preconceived ideas about weight and size got in the way.
Eventually, I had two normal vaginal births, and the recovery was so much better. And it was so much easier to take care of my older children and my newborns when not recovering from major surgery at the same time.
I want all women of size to know their size alone does not mean they need a cesarean. I want them to know that they have choices, and that they should question the routine interventions and protocols often recommended to women of size.
If, after looking at the risks and benefits, they decide to utilize these interventions, that’s OK. Different women can choose to birth in many different ways. There’s no one “right” way to give birth. But they need to be educated about their choices, and to know that being larger does not mean that their choices should be taken away from them.
In short, I want women of size to have the best possible chance at a healthy pregnancy and a healthy birth, and I want them to feel empowered about their choices along the way. I also want health care providers to initiate some real dialogue about improving health care for women of size, and to question their own assumptions about obesity and whether the commonly-accepted standard of care in this group really is improving outcome or not.
OBOS: What’s the level of misunderstanding and/or misinformation about obesity and cesarean sections?
PV: The level of misunderstanding and misinformation about obesity and cesareans is very high. Many doctors blame the current cesarean epidemic on obesity. Yet in the past, women of size had a much lower cesarean rate than today. If being fat truly prevented vaginal birth, there would have been a high cesarean rate in that group consistently across time, yet the rate used to be much, much lower. Fat women can give birth vaginally.
It’s time to stop scapegoating women for the high cesarean rate. Changing demographics may play a role, but providers need to acknowledge that the way they manage births has been a very significant factor in the tremendous rise in the cesarean rate. They need to take responsibility for their own contributions to the cesarean rate.
The cesarean rate does not need to be so high in women of any size, but given the risks of surgery in obese women, it is important that this intervention not be used routinely or unnecessarily in this group. Yet this has become almost the standard of care in obese women nowadays, and no one is questioning whether this is beneficial or whether anything can be done to lower the rate.
This article is intended to examine the research on the issue, question the high rate of cesareans in women of size, and increase the dialogue about what can be done to lower the rate.
OBOS: You write: “If the cesarean rate was significantly lower in the past for obese women, it means that most fat women can give birth vaginally under the right conditions, and that a high cesarean rate is not an inevitable outcome of obesity. Many of the cesareans in women of size today may be ‘iatrogenic’ — that is, caused by the attitudes and management protocols of the doctors, rather than by the woman’s size.”
What has caused such a tremendous shift in attitudes and management protocols?
PV: There are a number of factors that have come together to create such a huge shift in attitudes and management protocols. The explosion in the use of inductions, the decreased tolerance today for variations of normal, an exaggerated fear of the risks of obesity and pregnancy, the worship of technology without recognition that it can also introduce risks as well, and the improvements in cesarean technique that have made it safer than before have all added to the high cesarean rate in women of size.
There has generally been an explosion of induction of labor in this country. This is particularly true in women of size. Obese women are induced at very high rates, often before their bodies are truly ready for labor. The over-use of inductions, especially in first-time mothers or women whose cervices are not soft and ready for labor, greatly increases the risk for cesarean. Yet almost nowhere in the medical literature is anyone questioning the high induction rate in obese women.
There is also less tolerance today for variations of normal. For example, research has shown that women of size tend to have longer menstrual cycles, and therefore “longer” gestations. But rarely do care providers take that into account and adjust due dates. Ultrasounds to date the pregnancy can help compensate if the cycles are very long, but if the cycles are only a week or two longer than average, that’s often within the margin of error of the ultrasound. As a result, obese women’s due dates are rarely moved back, and this leads to a great deal of early intervention that is not needed.
Another problem has been the so-called “War on Obesity.” The perception of the health risks of fat people is so hyped that many doctors have exaggerated fears. They look at a pregnant woman of size and see only a ticking time bomb, ready to explode. Yet the fact is that many women of size have perfectly healthy pregnancies and births, but you’d never know that from reading an article about obesity in pregnancy in either the popular media or the medical research.
Doctors are human; they will respond to hyperbole about risks by increasing the levels of intervention they employ in those pregnancies. Yet nowhere is anyone asking whether those interventions actually improve outcomes or worsen them.
There is an attitude in modern obstetrics that more technology is always better, and that technology has great benefits but very little risk. This is particularly true in obesity and pregnancy. More tests are ordered, more interventions are performed, and no one is asking whether these things really ARE improving outcome in this group or not.
Most providers genuinely think they are doing the best for their obese clients by ordering more tests and bringing in the machine that goes “ping!” but research shows that every intervention has the potential for a dark side, and may actually bring more risk than benefit at times. From the many, many birth stories I have read involving women of size, I have observed that oftentimes the technology used actually adds to the cesarean rate instead of lowering it.
Another factor in the strong rise in the c-section rate in obese women is that improvements in surgical technique and in anesthesia have lowered the risks associated with cesareans. Now, there is a cavalier attitude that because cesareans are safer, it doesn’t matter how a woman gives birth. But just because cesareans are safer than they used to be doesn’t mean they are perfectly safe. Surgery inherently carries risks; do enough cesareans, and sooner or later you will see more cases of even the rare complications. And repeated cesareans carry even more risks. Just because cesareans are safer now in obese women doesn’t mean that they should be used routinely.
OBOS: Why have the management protocols changed so much — particularly when the medical evidence is not supportive?
PV: The way the media and some researchers “spin” the research on obesity in pregnancy influences doctors’ perception about risks, and many fail to ask critical questions of the conclusions.
For example, recent large studies on VBAC in obese women found that the VBAC success rate was lower for obese women than for average-sized women. Many providers therefore concluded that a trial of labor was pointless for obese women. Some even outright forbid a trial of labor for their obese clients.
However, a closer look at these studies show that about two-thirds of even “morbidly obese” women who had a trial of labor ended up with a VBAC. Although the VBAC success rate was lower in women of size, two-thirds of those who tried still had a VBAC, thereby sparing them from the significant risks of repeat surgeries.
A two-thirds VBAC success rate is a very respectable success rate in other studies; why is it only unacceptably low in obese women? But these studies have been routinely cited as a reason not to offer VBAC to women of size.
And no one has bothered to ask why the success rate was lower in women of size. Researchers failed to point out there were very high rates of induction in the obese group, which is known to lower the success rate of VBACs and may also increase complications. Researchers should be examining ways to improve the VBAC rate in women of size instead of implying that there is no point in even trying one at all.
Another factor is simply that the medical climate today simply does not encourage questioning the protocols that are convenient and profitable for them. Induction allows doctors to have more humane schedules and brings in more “billable services” for the hospitals. Litigation fears also play a role in increased cesarean rates, as does pressure from malpractice insurance companies for higher cesarean rates and less coverage of VBACs.
The reasons for the high cesarean rate in women of size are complex and multi-faceted, but the bottom line is that the rate is far too high and it does not need to be. Researchers must start asking the hard questions, examining their own biases and how this influences treatment, and looking for ways to lower the cesarean rate. They must stop thinking that the high cesarean rate is a natural consequence of obesity; it is not.
Care providers must start looking at ways to lower the cesarean rate in this group, and women of size must start being proactive about their pregnancies and birth-related care so that they can avoid cesareans that are not truly necessary.