Dec 282012
 

“I was hoping that you’d have a medical complication so that a home birth would be out of the question for you.” – Midwife at the 36 week prenatal appointment, while informing the mother that the planned home birth was off the table because of the mother’s preconception BMI.  The entire pregnancy and all prenatal tests, exams and ultrasounds were within normal limits.

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 December 28, 2012  Fatness, Home Birth, Midwife, prenatal  Add comments

  36 Responses to ““I Was Hoping THat You’d Have A Medical Complication So That A Home Birth Would Be Out Of The Question…””

  1. Wow, bait and switch much? If it wasn’t brought up as an issue immediately at the beginning, why such a big deal now?? SO frustrating!!

  2. Is this BMI horseshit the latest thing? I’m so tired of hearing about this! (Not to mention the fact that I heard it myself.)

    And I’m with Lisa. That was my thought exactly when it happened to me. Um, excuse me, but my PREPREGNANCY BMI cannot have possibly changed throughout the past ten months, so why are we just not having this conversation?

    I can’t believe this midwife would think this, let alone say it out loud (which can be said of so many comments on this site). How horrifying that she wouldn’t just woman up and tell OP at the beginning that she didn’t want to do a home birth because she’s fat-phobic. Nothing like informed consent.

    • This way the midwife still gets paid for each visit without having to attend the actual birth. Sometimes the difference between being paid for each visit vs. completing the maturity care contract is so small that it isn’t worth it to actually deliver the baby. Especially if you’ve taken on too many patients due around the same time and may not be able to fulfill your obligation to them all anyway. OP I’m sorry you were dumped at the last minute like this and I hope you were able to find a provider with more ethics than this one. You might be able to show that this midwife abandoned your care without proper notice.

      • I agree. At least in the USA, there are specifics about how a medical provider can kick someone out of her practice, and this midwife isn’t abiding by them. Especially because the pre-pregnancy BMI wasn’t going to change, the OP would probably get a great reception if she pursued the matter with whatever licensing boards are in her area.

        I think in the US, the regulation is that a provider must give 30 days written notice in order to remove someone from care for an ongoing condition. Since 36 weeks is very likely within 30 days of the delivery date, the midwife could be in a lot of hot water if this is within the US.

        • Unfortunately not going to work the same for a midwife as a doctor, however, unless the midwife has privleges at the local hospital. Because midwives, in every state where they are legal, are *required* to immediately ‘risk out’ anyone who they feel aren’t home birth safe or who meet specific state law requirements. But that’s for birth, not prenatal care. So a midwife could see you for prenatal care legally but then refuse to see you for the birth for any ‘risk’ and they aren’t going to be subjected to the whole 30 day thing for labor care. I might not be saying this quite right, but my basic point is midwives can’t be accused of legally abandoning a patient if there is a ‘risk’ that contraindicates a homebirth.

          • Thank you for clarifying. I hadn’t realized the medical abandonment laws would be different between practice types.

            It also occurs to me that if this midwife does attend hospital births, this quote might mean she’s changing the mom from a homebirth to a hospital birth while retaining her in the practice. Which makes the bait and switch just as nasty but more manipulative, since the midwife would still end up getting paid for the birth. :-b

          • That was my thought–that it’s not abandonment when she’s simply telling her she can’t deliver at home and will have to be in the hospital. You’re right, it’s especially nasty knowing that OP wants a home birth and taking that away from her at such a late time that it will be difficult to make other arrangements.

  3. Ah, the old “You’re completely healthy, but you’re fat, so you’re going to explode and destroy my ratings” bait-and-switch. Gotta love it.

    The ONLY scenario I can see where a care provider should give two thin fucks over a woman’s pre-pregnancy weight is if she’s super obese and a planned c-section — and only because extra abdominal fatty tissue is difficult to deal with during surgery. That just seems like an even BETTER reason to keep mom at home, where she has the lowest likelihood of needing a c-section.

    • EXACTLY! And yet we keep being told that overweight/obese women can’t give birth vaginally. What are we supposed to do–close our eyes, click our heels three times, and the baby magically appears before us?

      Oh wait, that’s right…I forgot what I read the other day. None of us are even supposed to get pregnant to begin with.

      • You can do that?!
        I totally would have done that instead of the whole labor-and-delivery thing.
        Way cooler.
        Do you need ruby shoes, too? Or can you just use crocs?

  4. Whiskey Tango Foxtrot on this one.

    How on earth would BMI affect anything? Many in the medical community are already throwing it out as useless, so to go to that to justify it…. I can’t. And to use the preconception numbers? It’s too damn DUMB.

    • As I have said many times, I think that BMI predicts health issues about as well as phrenology predicts character. But just like phrenology, BMI offers the seductive illusion of predictability. You know that those difficult patients are out there, just as you know that those bad employees are out there. Wouldn’t it be nice if you could see them coming? Wouldn’t it be great if you didn’t even have to engage these people? Just look at the chart–the BMI or the phrenological chart, it doesn’t matter–and you can mark off a sizeable enough percentage of your prospects that you can be confident of having kept the troublesome types out of your place of business. (Shock! horror! when the socially acceptably thin woman with the socially acceptably thin pregnancy develops a fat lady problem in pregnancy–or the man with the perfect head quietly doubles his own salary by embezzling from you.)

      Meanwhile people in the real world really suffer because of these neat little charts. Denied care now . . . denied jobs then.

      The midwife having strung the client along and bilked her for every possible penny is a whole other issue.

  5. My local midwives wouldn’t even ACCPECT me as a patient with this pregnancy because my BMI is too high.
    Funny, it was no issue with #2 & #3

  6. This is UNETHICAL. If the preconception BMI was an issue, it shouldn’t be brought up at the 36 week appointment. It should be brought up a) when the client was taken and/or b) when homebirth first came up (if it really is an issue at all).

    And as far as saying you HOPED a complication would come up….? Aurgh. Too bad one never did and you had to lie through your teeth, eh?

  7. Too bad we don’t live in a society where we can sue for misrepresentation.. oh wait…

  8. This is absolute horseshit. The midwife was hoping for a reason to risk the mother out and when she couldn’t find one she made one up? I would be livid.

  9. Wait, hold up! you WANTED something to go WRONG with my pregnancy?! So I would have to have a hospital birth?

    I really want to fire this midwife.

  10. Now I feel thankful that the midwife practice I chose for my first pregnancy only waited til after my third appointment to tell me I’d “have to” birth in the hospital. I wish the OP could have had more time to find and develop a relationship with a better midwife like I did.

  11. This is such crap I delivered my baby boy at HOME, and I have a BMI of 41. Its totally possible. What a dirty trick.

    • I had three successful labors at about the same BMI. I still don’t see what the size of my butt has to do with the strength of my CV system or my uterine muscles.

    • Yep–my sister has given birth in a hospital, but she has had four uncomplicated vaginal births and has a BMI of at least 35. My sister-in-law who is a stick had such a difficult vaginal birth with her son (third degree tearing, pain that lasted for months after delivery) that she ended up just scheduling a c-section with her daughter because of being concerned about re-tearing.

      BMI predicts how your birth will go, my ass.

      • Oh–and when I got pregnant with my son who ended up being a c-section for “failure to descend,” my pre-pregnancy BMI was 25.8 (aka barely “overweight”). When I got pregnant with my daughter, who ended up being an unmedicated VBAC, I was 30.0 (aka exactly “obese”).

  12. Well had I known that my BMI would make birth a “complication” I wouldn’t have had my last 6 babies at home UNASSISTED! LMAO

    Seems to me, my BMI was never an issue for ME when I gave birth. And my first was a c/s and second a hospital VBAC.

    Guess it’s a good thing I didn’t use a fat-phobic midwife or OB!

  13. This could’ve been my story. It’s not, since I ran. But this is the kind of thing I’d have expected during my second pregnancy.

    I’m Dutch and homebirth is quite normal. In fact, every healthy pregnant woman has a choice and they’re all seen by homebirth medwives (that’s not a typo). For my first pregnancy I has a BMI of around 22, which looked awfully thin on me by the way, and all was well. In the end, a complication forced me in to the hospital. I hated that and never wanted to birth there again.

    For my 2nd pregnancy I gained weight, now at a BMI of 30.7. Still not shocking, but definitely overweight. At my 20 week appointment I was asked about my preferences and said I wanted to birth at home. At that point I was told I couldn’t, since they didn’t “let” women with a (preconception) BMI over 30 birth at home. I now knew much more about my rights to informed consent so I told them that I wasn’t going to agree to that and knew they had no right to force me. Then I got the “dead mother” card, because I’d have a high chance of bleeding to death with my BMI, apparently. At that point I started to consider finishing the pregnancy unassisted, but heard that once you’re “in the system” it could be difficult to do that without getting into trouble and I was pretty much unprepared at that point so I found an actual midwife who attended my home waterbirth 20 weeks later.

    When I told the medwife practice that I was going to take my business elsewhere, they tried to convince me not to by telling me that I could have a homebirth if I agreed to all the tests I had declined at the start of my pregnancy. I didn’t trust them since there had been so much discussion already, and I had some specific wishes about this birth (no cervical checks, no coaching, delayed cord clamping, to name a few) and didn’t trust them to honor my wishes. And I was right, when I got my file from them, it turned out, from their pricvate notes in said file, that they (3 medwives in that practice) had decided that under no circumstances was I allowed to give birth at home and they had already decided upon all of the interventions I was going to “need”.

    Typically, the care provider does a check of your home as you reach 37 weeks to make sure there’s enough room etc. to have a home birth so we think they would’ve made something up at that point, or even during my birth, why we would have to go to the hospital in stead.

    In the end, it was well worth it to switch care providers, even though my MIDwife’s services weren’t covered by insurance. I had a beautiful home birth, 100% hands off, cord clamped after it stopped pulsating, no unneeded interventions. Laboured for about 5 hours, pushed for over an hour but, only had a very minor laceration as opposed to the very painful episiotomy I got with my first.

    Right now I’m having an unassisted pregnancy and in about 2 months, an unassisted birth. My BMI never changed. My confidence did.

    • Wow, cat, you are so lucky you got away from the first place! It’s amazing they actually put that information in your file. I can pretty much guarantee you that here in the U.S. they’d have put it on sticky notes, and pulled them off prior to making copies. You still would’ve been away, but without that very interesting information.

      Enjoy your UC! I’m jealous :)

    • hmm. in the US 22 is overweight and 30 is considered obese. I guess I’d be overweight in your area lol.
      And I agree with Wendy. US docs would’ve removed the notations (or blacked them out as “unnecessary/private” information

  14. While it is nice to hear the stories of successful home births, the statistics do show that increased BMI does increase your risk of complications in delivery. That doesn’t mean something will go wrong, or won’t for those with a normal weight, but just changes the risk.
    Not that that excuses the behaviour of this midwife – she should have been clear what she was happy with from the start and given you the option to discuss it with someone else.

    • But are the risks increased because of hospital policies, or because of large women. Labour and delivery seems to be a “one size, fits all” situation when it comes to hospital policies and it just doesn’t work that way. Not for thin women and not for large/larger women. Perhaps those policies are harder on larger women though. Aside from the fact that women of size are treated with much less respect. Women know this. And it makes their labour that much harder because they are stressed to begin with.
      Besides the risks aren’t THAT much higher. And every woman large or small has the right to informed consent and not getting the information until you’re 36 weeks pregnant gives you a tiny window of opportunity to be informed and consider consent. Or not.

    • Unfortunately, the biggest flaw with what few studies we have are that they entirely fail to account for provider management preferences or biases. We see higher rates of induction and c/s, but not necessarily higher *indication* for them. We see more hemorrhaging, but no effort made to reduce the interventions that lead to hemorrhage (surgery, induction/augmentation, episiotomy, cord traction). This is actually true for a number of maternity-related topics, but until provider bias is ruled out and births under study are managed in an entirely evidence-based manner there will be no accurate way to measure risks between populations of birthing women. And when it comes to the BMI question, the risk increase (even with all the non-evidence-based management) is not large. Thus, the risks, such as they are, and benefits should be discussed respectfully and honestly with potential clients so they can make their own decisions about their care.

      • Aron, I love your eloquence and clarity when you explain things. You take something that could have been complicated and make it understandable to lay-people like me, but in a respectful way, not condescending. Thank you!

  15. Aron, I fully agree, provider bias does make interpretation different, but it is worth considering that the change in provider behaviour is trying to minimise the most adverse outcomes.
    Also, I would be cautious about describing the risk increase as “not large”. Studies have consistently shown a doubling in post partum haemorrhage, stillbirth, and 2-3x fetal abnormalities (for example spina bifida or cardiac). In addition, there is a 50% higher rate of Neonatal ICU admission and increase rates of Preeclampsia, hypertension and gestational diabetes. While there is a degree of variation in different weight groups, increasing BMI is independently associated with emergency CS with spontaneous and induced labour, along with greater postoperative complications. And an increase in thromboembolism.
    Sorry for any dodgy spelling and grammar – iPhone working against me!
    (UK) Data for above:
    http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/CMACE/CMACE_Obesity_Report_2010_Final%20for%20printing.pdf

    • I haven’t checked the link (sorry), but I want to point out that doubling risk doesn’t always equal high risk. If I double a 1% risk that only makes it 2%.

    • ALSO, how much of this doubling can be attributed to caretakers not taking patents’ symptoms seriously because the medical community likes to blame symptoms on “teh fatt”?

    • I think the conversation got away from the original topic. The point is that this mother was healthy and the only reason the midwife pushed her off was BMI. I think the first posters were trying to stress that BMI is not a valid reason for medical interventions and c-sections. Now if overweight and obese BMIs lead to preeclampsia, gestational diabetes, and other complications then the conversation of medical interventions may be necessary. But for a care provider to automatically have the mindset that women with a certain BMI range will automatically have complications and not dicuss this with all patients immediately is deceitful and bad business practices.

      Can we get the name of this midwife so we know not to patronize her? :D

      BTW, my overweight aunt had her 3rd child vaginally with GD and a BMI over 30 with no meds 10 years ago.
      My sis in law was not even allowed to go into labor at 20 years old with a BMI over 30 a year ago.

  16. Gasman is correct that high maternal BMI is associated with higher rates of complications, but using odds ratios is a good way to distort the sense of complications around obesity in pregnancy.

    Yes, the risk for birth defects is higher, about doubled (depends on the study), but twice the risk of a very small risk is still a small risk. The risk of an neural tube defect like spina bifida, while increased, is still less than 1% in obese women. And is it increased because of obesity itself or because there is an increased rate of hyperinsulinemia due to PCOS or because obese women need higher doses of folic acid or are there subtle metabolic differences that cause both obesity and a higher rate of complications? We need more meaningful research that delves into causes, not merely reports associations.

    I’m not a fan of folks pretending there are no risks around obesity and pregnancy, but I also have a lot of problems with the way authorities exaggerate these risks and then cause more risks by overintervening in our pregnancies and labors and then blaming “obesity” for the results.

    The truth is more nuanced than that, and what is really missing in this discussion is a nuanced point of view. You can read more about this at my blog, http://www.wellroundedmama.blogspot.com, and in the series I did at Science and Sensibility:

    http://www.scienceandsensibility.org/?p=3030
    http://www.scienceandsensibility.org/?p=3064
    http://www.scienceandsensibility.org/?p=3094

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