Sunday, 25 September 2016

Routine Planned Cesareans in Older Mothers Do More Harm Than Good


Many care providers push strongly for elective (planned) cesareans in older moms. However, a recent study challenges the wisdom of this common practice.

This extremely large study confirms that planned cesareans as a routine intervention for older moms is a bad idea. It increased their risk for infection, hysterectomy, kidney failure, cardiac arrest, and death.

This is an issue close to my heart as I was an "AMA" (Advanced Maternal Age, or 35 or older) mom for three of my four pregnancies.

In many practices, a woman like me ─ an older "morbidly obese" mother with a prior cesarean ─ would have faced intense pressure for a planned cesarean. I was fortunate to have care providers that didn't pressure me to have a cesarean just because of my age or weight. (Then again, I purposely chose providers who utilized a more low-intervention model.)

But the pressure for a planned cesarean can be quite strong on older mothers in many practices, especially if the mother is a first-time mom or received fertility treatment. One study found four times the rate of elective cesareans in older first-time moms. But why?

Some doctors see vaginal birth in an older mom as so risky that they prefer to just bypass labor altogether and plan a cesarean. Although the risk for stillbirth does seem to go up somewhat as women age, recent research confirms that this risk is quite modest (and not all research finds an increase in risk). Most healthy older women will do just fine.

Furthermore, a recent study confirms that the difference in outcomes between planned cesareans and planned vaginal births in older moms is quite small. Each choice has its own pros and cons to consider.

Risks probably increase as a woman ages; a woman of 54 probably has a much different risk than a woman of 41. However, many women with very advanced maternal ages have safe vaginal births too. Age alone should not be used as an absolute guide for a planned cesarean.

Although the risk for needing a cesarean during labor does increase as a woman gets older, the research shows that the majority of older women who are given a chance at having a vaginal birth actually do give birth normally. Giving birth under the care of midwives or in a non-obstetric unit setting may improve chances for a vaginal birth in older women who labor.

That is not to say that a planned cesarean is never appropriate in an older mom, only that the decision should be a nuanced one. Risks are higher in those with multiples, with those who have their first pregnancies after 40, and in those who required fertility treatments. Older women who have serious pre-existing health conditions, who have multiple major risk factors, or whose babies do not seem to be growing well have a much different risk profile than an older woman who is healthy, has no pregnancy complications, and has a healthy baby who is growing well.

It would be nice to see further research that provided concrete quantification of absolute risks at various ages in combination with various risk factors. That would be more helpful in guiding decision-making.

Still, all the factors must be considered and birth decisions should be made by the woman and her providers together. The decision should never be imposed on a woman by her provider; age does not negate a woman's right to personal autonomy in her medical decisions.

The bottom line is that routine use of a planned cesarean in older women simply because of age puts that mother's health at risk. Better to have the mother go into labor and see how labor goes. A cesarean can be done in labor if needed, but this very large study shows that routine cesareans for age leads to greater harm overall.

As the authors of the study conclude:
Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.
For an excellent review of the overall research around pregnancy in ages 35 and older, please see this article.


Reference

Matern Child Health J. 2016 Jul 29. [Epub ahead of print] Effect of Planned Mode of Delivery in Women with Advanced Maternal Age. Lavecchia M1, Sabbah M1, Abenhaim HA2,3. PMID: 27473092
OBJECTIVES: The purpose of this study was to determine the prognostic value of planned primary elective cesarean section versus planned vaginal delivery in women with advanced maternal age. METHODS: We conducted a population-based, retrospective cohort study using the United States' Health Care Cost and Utilization Project's Nationwide Inpatient Sample to evaluate maternal outcomes in women with advanced maternal age delivering from 2003 to 2012. Healthy women who underwent primary elective cesarean section constituted a surrogate for low-risk planned cesarean delivery. Logistic regression was used to compare outcomes between women with planned cesarean and planned vaginal delivery. RESULTS: Among seven million births, we identified 442,067 deliveries in healthy women with advanced maternal age. The planned cesarean group comprised 7.96 % of women in the cohort. When compared to healthy women in the planned vaginal group, women in the planned cesarean group had a significantly higher mortality ratio (2.56/10,000 vs. 0.44/10,000, p < 0.01). The planned cesarean group was also at higher odds of numerous complications, including peripartum hysterectomy OR 1.81 (1.36-2.40), p < 0.01, cardiac arrest OR 5.39 (4.54-6.38), p < 0.01, acute renal failure OR 3.39 (1.78-6.46), p < 0.01 and sepsis OR 2.27 (1.25-4.14), p < 0.01. CONCLUSIONS FOR PRACTICE: Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.


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Saturday, 24 September 2016

Binge Eating Disorder

This post isn’t really about fatness, but I was thinking about binge eating disorder as a diagnosis. You can take a look at the diagnostic criteria here, but it seems to get into a thorny realm because one criterion is a sense of lack of control. To me, that sounds like saying “addictive behavior” while avoiding that phrase. It leads to some questions:

  • Is binge eating itself a problem, or just a symptom of a deeper problem?
  • Does this diagnosis really help people?
  • Is there an issue with the diagnosis being incorrectly applied to fat people?
  • The diagnosis also mentions distress, disgust, etc. If one binges without these feelings, does one have the disorder?

I don’t have a firm viewpoint, but I’d like to hear yours.




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September NAAFA Newsletter

I forgot to post the link to this month’s NAAFA newsletter last week; sorry about that. But here it is, and I’ve pre-clicked for you so that the link below takes you straight to the fat news. Enjoy!

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Friday, 23 September 2016

Happy Bi Visibility Day!

It’s Bi Visibility Week, and today is apparently also Bi Visibility Day!  In honor of that, a couple quick things:

  • First, hi, world, I’m bisexual.  (I’ve referred to myself as “mostly straight: in the past, and why it took me a while to actually claim the label of “bi” is probably its own post.)
  • Second, Samantha Field is an amazing bisexual progressive Christian blogger who you should read.  She does book reviews deconstructing evangelical favorites like “I Kissed Dating Goodbye” and the Christian romance novel “Redeeming Love.”  (Fat acceptance isn’t her focus, but she calls out fatphobia when she sees it.



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In Defense of Racists?

Last week and part of this week was vacation; my first ever all by myself drive to and from Sudbury to the Sault to visit with family and friends. It was spectacular in that it was perfectly ordinary; coffee with one friend, lunch with another, hitting Pokestops downtown one night and a sleepover at camp another. It feels like I took a million pictures but it was more like 300-foxes at breakfast, a selfie with my neice, storm clouds and a rainbow while on a walk with mom, exposed rock bluffs and the marbled ancient shoreline of my favourite lake. If you're interested an album will be up on the Facebook page soon.

The serenity of my vacation was ruined by Canadian Soldiers of Odin and straight up old fashioned racism. Watching the news in the evening with my dad was challenging to say the least. He's in his 60s and holds conservative ideas and values; I learned that Hillary Clinton is a lying bitch about Benghazi but at least he also thinks that Trump is a sociopath. We can't let in any more refugees because they're dangerous (I wont repeat what he said here but it stunned me) thanks to the news out of Manhattan and New Jersey. Also, the Soldiers of Odin have set up a chapter in the Sault and are trying to start one in Sudbury, and I just can't even because a FB friend of mine is all for that, and I bet a few other people are as well but haven't said so YET. Sure they're doing food drives and picking up needles and, in some cities, patrolling the streets at night as a neighbourhood watch group, but despite ALL the Canadian chapters so far vehemently stating they're not like the extreme anti-immigrant group in Finland, that they're not racist, just good citizens who want to Do Something, I'm not convinced. 

I spent a couple of hours combing the Sault's FB page and found this manifesto written by one of the admins. Here's a small excerpt:

     "What I fight against is the injustice done to Canadians who are forced to change their way of life to accomodate people who immigrate here. I fight against the basic upheaval of our culture and beliefs under the guise of "tolerance" or "political correctness". I see the Canada I grew up in changing every day and not for better. I almost can't recognize the country of my youth where I was free to say "Merry Christmas" without the fear of someone taking offense to my sincere well wishes. Where we accepted those of other cultures openly and freely but we did not allow them to change who we are on a fundemental level as we are today. Would you come as a guest into my home and then demand that I allow you to wear shoes where we do not and tread mud on my floor? This is what is being done to Canada. This is the threat to our way of life. Please, come to my country, enjoy the same quality of life that I enjoy. But don't ask us to change the rules of our house to make you more comfortable."

The two admins public Facebook posts also have racist memes and similar comments. I'm having a bad attack of NIMBY: Not In My Back Yard. It's one thing to be aware of the racism and small-minded conservative thinking in my hometown, it's another thing to see it walking around out in the open wearing a leather jacket. Soldiers of Odin isn't anti-immigrant or racist? Sure, you keep telling yourself that. By deliberately choosing to start a chapter of SOO they've chosen to take on all the garbage associated with them.

On the other hand, they did go out the other night and pick up a shit-ton of dirty needles in a bad part of town. They actually ARE doing food drives and helping out. But would I say the same if they were the KKK and I lived in Alabama? If I wasn't a white chick who grew up here? Or is the extremism not bad enough? Where do I draw the line to say "Fuck the good people?" People like my dad who have spent 30 years doing volunteer work with Search and Rescue, helping out friends and family alike with home improvement projects, and doesn't buy Christmas presents but donates to the Sault Star Santa Fund instead? Is he my enemy? He's definitely the kind of guy on Twitter I'd take apart for his racism. If he showed up in my FB feed arguing that the SOO group in the Sault was a Good Thing and why the heck does the name matter so damn much? I'd feed him logic until his head explodes.

But he's my dad.

The Soldiers of Odin have done something here in Canada that noone else has been able to do before; give a legitimate face to the anti-immigrant, right wing conservative racism that's been lurking at the edges for a while now. It's one thing to laugh at the good ol' boys in the rural areas with their quads, beer, guns, and their backwards thinking. It's entirely different when those people put on a uniform, declare they're a part of a unified front, and start patrolling the streets. And I worry that if dad was 30 years younger, he'd join them.

 

 



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Monday, 19 September 2016

Estimating Fetal Weight Increases Cesarean Risk

Image from Wikimedia
One intervention often seen in pregnancies these days is estimation of fetal weight. But does this improve outcomes?

Bigger babies are more at risk for getting stuck, which is called "shoulder dystocia." Although the actual numerical risk for shoulder dystocia with big babies is not very great (and small babies get stuck too), the risk for shoulder dystocia is higher with a bigger baby. Most of the time it is resolved without damage, but in some cases babies or moms are hurt, sometimes seriously. In rare cases, babies even die. Damage from shoulder dystocia is one of the main reasons care providers get sued.

As a result, a big baby make many care providers nervous. So they routinely employ estimation of fetal weight near the end of pregnancy, either by hands-on estimation or by ultrasound estimation. But the critical question is whether estimating fetal weight actually improves outcomes.

Here is yet another study that shows that estimating fetal weight does NOT improve outcomes and that it increases the risk for cesareans. 

In this very large multi-center MFMU study, a baby estimated to be above 4000g (8 lbs., 13 oz.) was more than twice as likely to be born by cesarean. A diabetic mother with a baby estimated to be above 3500g (about 7 lbs. 12 oz.) was more than nine times as likely to have a cesarean.

This relationship persisted even when adjusted for actual birth weight and other variables, showing it was not just about the baby's size. The mere prediction of a large baby (whether baby was actually large or not) increased the risk for cesarean, suggesting that it is the way big babies are managed that makes the difference.

This is a particularly pertinent issue for women of size. Because "obese" women tend to have larger babies on average, care providers can get very anxious about fetal size in their pregnancies. Fear of big baby (and the resulting interventions) is one of the top drivers around the outrageously high cesarean rate in high-BMI women.

Sadly, this study does not directly address the effect of fetal weight estimation in the sub-population of obese women. It would be great to have data actually examining a practice that is so common in the management of obese women.

However, this is a very large and very powerful study showing that the practice of estimating fetal weight is harmful in pregnant women in general.

And it is just the latest in a long series of studies that show that the common practice of estimating fetal weight increases the cesarean rate.

Given that it is such a common practice in obstetrics these days, the practice of estimating fetal size before birth needs to be re-evaluated. 

There are times when estimating fetal size can be appropriate, but most of the time it is more harmful than helpful. Care providers need to stop using it routinely.

And its use especially needs to be evaluated in the management of women of size.


Reference

Obstet Gynecol. 2016 Sep;128(3):487-94. doi: 10.1097/AOG.0000000000001571. Association of Recorded Estimated Fetal Weight and Cesarean Delivery in Attempted Vaginal Delivery at Term. Froehlich RJ1, Sandoval G, Bailit JL, Grobman WA, Reddy UM, Wapner RJ, Varner MW, Thorp JM Jr, Prasad M, Tita AT, Saade G, Sorokin Y,Blackwell SC, Tolosa JE; MSCE, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. PMID: 27500344
OBJECTIVE: To evaluate the association between documentation of estimated fetal weight, and its value, with cesarean delivery. METHODS: This was a secondary analysis of a multicenter observational cohort of 115,502 deliveries from 2008 to 2011. Data were abstracted by trained and certified study personnel. We included women at 37 weeks of gestation or greater attempting vaginal delivery with live, nonanomalous, singleton, vertex fetuses and no history of cesarean delivery. Rates and odds ratios (ORs) were calculated for women with ultrasonography or clinical estimated fetal weight compared with women without documentation of estimated fetal weight. Further subgroup analyses were performed for estimated fetal weight categories (less than 3,500, 3,500-3,999, and 4,000 g or greater) stratified by diabetic status. Multivariable analyses were performed to adjust for important potential confounding variables. RESULTS: We included 64,030 women. Cesarean delivery rates were 18.5% in the ultrasound estimated fetal weight group, 13.4% in the clinical estimated fetal weight group, and 11.7% in the no documented estimated fetal weight group (P<.001). After adjustment (including for birth weight), the adjusted OR of cesarean delivery was 1.44 (95% confidence interval [CI] 1.31-1.58, P<.001) for women with ultrasound estimated fetal weight and 1.08 for clinical estimated fetal weight (95% CI 1.01-1.15, P=.017) compared with women with no documented estimated fetal weight (referent). The highest estimates of fetal weight conveyed the greatest odds of cesarean delivery. When ultrasound estimated fetal weight was 4,000 g or greater, the adjusted OR was 2.15 (95% CI 1.55-2.98, P<.001) in women without diabetes and 9.00 (95% CI 3.65-22.17, P<.001) in women with diabetes compared to those with estimated fetal weight less than 3,500 g. CONCLUSION: In this contemporary cohort of women attempting vaginal delivery at term, documentation of estimated fetal weight (obtained clinically or, particularly, by ultrasonography) was associated with increased odds of cesarean delivery. This relationship was strongest at higher fetal weight estimates, even after controlling for the effects of birth weight and other factors associated with increased cesarean delivery risk.


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On spaces for fat activism and scholarship

As a super fat person living in New Zealand, I am rarely afforded the opportunity to hang out in fat spaces offline. I don’t know many fat people who embrace that identity, so I am always keen to have access to spaces designed by fat people, for fat people, about fat people. One of those yearly spaces (albeit online) is the Fat Activism Conference(FAC). This began in 2014, organised by Ragan Chastain of DancewithFat and Jeannette DePattie from The Fat Chick. This year, I’m pleased to be part of the organising team; doing my part to encourage that speakers are invited from all parts of the world, not just the Western Northern Hemisphere. And I’m excited that my radio show, Friend of Marilyn, has come on board as a Gold Sponsor this year!

2016-08-20-22-47-08

There’s a lot to love about this conference. It’s online, so you can access it from anywhere in the world on your phone or computer. If you can’t join the conference live (like me, due to time differences), you can listen to the recorded sessions at your leisure. Plus, this year they are providing transcripts. FAC runs from 23-25 September 2016.

The keynotes this year are Jill Andrew, Charlotte Cooper, Caleb Luna, and Dianne Bondy. Other speakers include Bevin Branlandingham, Alysse Dalessandro, Rajah Jones, Gloria Lucas, Mirna Valerio, and me (find them all here). One of the things I LOVE about these kinds of events are the opportunities afforded to fat people to share their stories – their truths – their experiences. Fat people are excluded from the narratives around fatness in favour of “experts on obesity”.

Another great aspect is the accessibility of FAC. There are passes at affordable prices, that gain you access to the sessions and transcripts, plus extras. And there is a pay-what-you-can-afford option too! Fat activism is important because fat hate hurts people of all sizes – and while we may not be able to change everyone’s mind about fatness, we can damn sure make it illegal to discriminate against us for our size. And we can strive for a society in which fat people are able to lead their lives the way they want, without apology or shame.

Register now to attend FAC 2016 (this is my affiliate link)!

If you are interested in fat scholarship, then make sure to check out FSNZ16!

(re-posted from the Health at Every Size blog)

Fat Studies: Identity, Agency, Embodiment (FSNZ16) was the second Fat Studies conference I’ve hosted in New Zealand. It provided a space for Fat Studies scholars and fat activists to come together and share pedagogy, scholarship, and activism. It was well supported by my Institution and received a great deal of media attention across New Zealand. Having hosted Fat Studies: Reflective Intersections in 2012, colleagues, admin, and the media alike, were not confounded by the idea of a Fat Studies conference this go around; a Fat Studies conference no longer seems odd, or, as odd, to the people in New Zealand.

cat1We had 22 speakers from eight countries across four continents; 5 of them joined remotely (a New Zealander with a sick child on the day, and individuals from Australia, Canada, the United States, and the United Kingdom). All of the presentations were well received; one of the most popular was from a postgrad student, Jessica Maclean, who shared at the start that it was her first academic presentation. Our two keynotes were fantastic. Having two keynotes: one academic, Katie LeBesco, and one activist, Substantia Jones, drew attendees from across two crowds and acknowledged that Fat Studies is a discipline heavily influenced by both scholars and activists alike.

While we had presenters from 8 countries, I was disappointed that we were a space that (re)produced white supremacy; both keynotes were white, most speakers and attendees were white. This was further reinforced by the pictures supplied by presenters to use in the promotion material; we only had one picture from a POC to use in our materials. The organising committee had sought to ensure we had POC on the committee, and that our CFP reached out to feminist spaces, student spaces, and spaces for people of colour. We worked especially hard to engage with the indigenous communities in New Zealand. When all was said and done, though, we failed to produce a conference that represented a diverse group of voices. We are working on strategies to ensure that future FSNZ conferences do better, including a commitment to having a POC as a keynote.

Of our registrations, many of those were online registrations.  One of the drawbacks of hosting FSNZ is that many people are unable to attend a conference in New Zealand in person. Online attendees were able to live stream the two days, and submit Qs for presenters through Twitter; online participation allowed access to those unable to join us in New Zealand, and live tweeting allowed for engagement with those not in the room. Live Tweeting of FSNZ16 took place by four individuals in attendance, along with the organiser. Presenters were requested to provide 3-5 tweets (or bits that could be revised into tweets) beforehand; in total, the conference account (@FSNZ2016) tweeted about 325 times during the two days.

Financially, the conference was tenuous. Many academic conferences are now supported or sponsored by industry; this has almost become an expectation within academia. As we do not have a large industry that could support us, FSNZ16 relied solely on registrations and financial support from the University. This makes us vulnerable to budget capacities of the institution, and to the willingness of the fat community to support the conference. In fact, we are still looking for fat community support, ascat2 registration remains open until 30 September for those who wish to access the recorded presentations from the conference. The price has been dropped to 25NZD/18USD, and we hope there are many out there who are willing to support us and ensure that FSNZ happens again!

Before the conference kicked off, a spoken word event was held at the public library. Fat Out Loud was hosted by Dr. Jenny Lee and myself, and we were thrilled to have six readers share stories about being pregnant while fat, being a fat child, negotiating life with an anti-fat mother, rejecting suitors who won’t be seen with you in public, and the role of chairs in the lives of fat people. You can find videos of two of those readings in this playlist. The closing night of the conference, The Adipositivity Project exhibit opened at Te Manawa, a local art gallery and museum.

For me, one of the most valuable aspects of the conference is the opportunity for community. To be in a space for fat people, with fat voices at the fore, is rare for me. As Kath Read of the Fat Heffalump wrote,

cat3But most of all, what I valued the most was the community.  This was a room full of people whom I did not have to educate from scratch.  This is almost unheard of for me – I spend the majority of my time engaging in Fat Activism 101, where I constantly have to justify the right of fat people to have a life of dignity and respect – something I have been doing for almost 8 long, long years.   I did not have to explain to any of the attendees the basic tenets of fat activism.  We spoke a common language, and are approaching the topic from a similar direction.  Not to mention, generally speaking, people engaging in fat studies are not looking to eradicate, cure or prevent fatness.  They’re looking at what it means to live in a fat body, how society treats fat people and how we can maintain fat people’s rights.

If you are able to support Fat Studies scholarship, please register for FSNZ16. You’ll get the full programme, along with recorded presentations from the two days. If you’d like access to the videos, but cannot afford the registration fee, please let me know and I will arrange for a scholarship for you!

 

 



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