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Is Weight a Contraindication for Homebirth?

Practice Variation in Cesarean Rates: Not Due to Maternal Complications
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients.  This analysis shows that:

    Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
    Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
    Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.

Tips for Choosing a Care Provider - great overview! from Henci Goer

I'm a homebirth midwife, and I don't agree that weight alone should be a contra-indication to a homebirth. The only good reason I can think of is that there might be a time when the birth attendants might need to help the mom change positions, and moving a larger woman will require more strength on the part of the birth attendants. This was a serious consideration in the days when homebirth midwives were scarce and often worked completely alone. Then, it was common for just the midwife and the birthing woman's partner to be the only adults present. These days, in our area anyway, most midwives bring a second midwife and sometimes an apprentice or labor coach. Together with the woman's family, this should be enough muscle to move any woman.

The subject has come up several times on the midwife list, and the consensus among both homebirth and hospital midwives is that size has little to do with giving birth. In particular, there are homebirth midwives who serve Amish communities, where many of the women are large. These midwives say they haven't noticed any particular problems due to size.

Let's take a look at what _Williams Obstetrics_ says about it.

First, it admits that there's no standardized definition of obesity, so investigators have used a variety of classifications, generally based on weight alone, ignoring muscle mass or strength.

Here's a list of their "complications due to obesity", with my comments. And, for the record, their definition of obesity is > 250, and this is compared with women weighing < 200. It sounds as if there isn't a lot of clear evidence regarding the 200-250 pound zone.

Complications during pregnancy are limited to diabetes and hypertension. Well, these alone could be contra-indications to homebirth. If they're not there, they're not there, regardless of the woman's size. If the woman is healthy at 39 weeks, it seems unlikely that she will develop these complications simply because she gives birth at home.

Another "complication" is a postterm pregnancy. Well, personally, it makes sense to me that women with slower metabolisms are going to grow babies more slowly. This is only a complication in the medico-legal sense. Biophysical profiles can be done to assess postterm fetal well-being, regardless of maternal size.

The remaining "complications" are pitocin induction and augmentation. Well, the increased induction obviously comes from the increased rate of postterm babies, and from the medico-legal fear that "the baby will be big".

In fact, "macrosomic infants" are another one of the complications, meaning that large women have large babies. The only substantive related "complication" is shoulder dystocia. Listing this as a complication is completely specious, as all OBs agree that there is no way prenatally to predict shoulder dystocia. There are only ways to predict that you will lose a lawsuit if there's a problem. (And, by the way, most reported incidents of "shoulder dystocia" are really tight shoulders, which one might expect to see in a woman with a well-padded pelvis. This is very different from a case of real shoulder dystocia, which is only about bone, i.e. the baby's shoulder bone becoming impacted behind the mother's pubic bone.)

Other "complications" listed are surgical - cesareans, resulting infection and blood loss.

Despite their alleged scientific approach, no evidence is presented that the size of a healthy woman has any bearing on outcome. No distinction is made between large, healthy women and large women with diabetes and hypertension. If there is an increased rate of diabetes and hypertension in larger women, then, yes, the overall statistics will reflect the increased rate of "complications" that one would expect from diabetes and hypertension.

Personally, I think weight restrictions alone are an extension of our cultural prejudice against women who don't conform to expectations that they should remain as small as possible.

Let's look at how _Williams Obstetrics_ presents the issue of underweight women and Intrauterine Fetal Growth Retardation.

Ah, here they start to look at the difference between healthy circumstances and pathological circumstances, rather than making blanket statements that underweight women have increased rates of complications. They point out that it's important to understand the many causes, and that about 75 percent of small-for-gestation-age infants are constitutionally small. "Small women typically have smaller babies. . . . In a small woman with a small pelvis, the birth of a small baby whose genetically determined weight is below the average for the entire population is not necessarily an undesirable event."

One could make analogous statements about large women and large babies, but they don't.

Oddly enough, this is the section where they start to make some sense about large women. "If the mother is large and otherwise healthy, however, below-average maternal weight gain without maternal disease is unlikely to be associated with appreciable fetal growth retardation. Marked restriction of weight gain during pregnancy should not be encouraged."

So, they're a little inconsistent.

If anyone tells you that size is a problem in a healthy woman giving birth, ask for some real studies, not just prejudice.



This Web page is referenced from other pages containing related information about Miscellaneous Prenatal Information and Homebirth Safety/Advocacy

 




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