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    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to

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    Archived User

    I have a friend who is finally pregnant after 5 years of infertility.  She went to her doctor's appt today and was told that if she gained anymore weight she would need a c-section.  She admits that she is overweight, but has been vigilant in her diet and is exercising daily, unfortunately she can't seem to keep the weight off.

    Is there any reason that being overweight would automatically equal c-section?

    Henci Goer

    No, but her doctor's statement is a good reason to find another care provider ASAP. Her doctor's belief in her inability to birth vaginally is extremely likely to become a self-fulfilling prophecy. The research is rock solid that cesarean rates depend far more on the individual care provider's judgment and practices than on factors that have to do with the woman. Here is a web site dedicated to pregnancy and birth in women of size that should prove helpful to your friend. By coincidence, the current blog post on the site's associated blog, "The Well-Rounded Mama," is on finding a care provider.

    While I'm at it, it sounds like your friend is taking good care of herself. She should know, though, that high BMI women should not attempt to lose weight or hold the line while pregnant. They should gain weight, but not as much as the average or low BMI woman.

    Finally, if she has had difficulty conceiving, she may be especially vulnerable to the "premium baby" argument that a cesarean will be safest and best for her baby. This is absolutely false. Here is a link to a page on the Lamaze website on what best promotes safe, healthy birth.

    -- Henci 

    Archived User

    Henci, I'd like to know more about healthy weight gain in an obese expectant woman.  I'm a midwife and have always recommended little to no weight gain in my obese mamas.  I had one woman who was 5' 4" 315 lbs. and planning her 3rd birth at home after 2 in the hospital.  She lost 13 lbs. during this pregnancy and I actually told her this was okay.  Unlike her 1st and 2nd babies who came 3 and 4 weeks early, she took this one to 40 weeks and it weighed 9 pounds (her others were 6 1/2 and 7).  Was this just unusual?  My women are all healthy Mennonite women who eat well and exercise.  I have example after example of women who gain little and have healthy outcomes.  I'm currently worried about my advice to a woman who is 4'10" and weighs 175 lbs.  I'm asking her not to gain weight at all and she has lost 2 or 3 lbs. by 26 wks.  She is expecting her 4th baby and all have been c-section and she is planning another c-section.  In my 11 years as a midwife, my nutritional advice has always been the same with overweight or obese women and the outcomes have always been apparently, great.  I'd hate to think I'm doing something harmful to these women or babies. I would really appreciate your advice.  Oh, and as a side comment...I was an OB nurse for 10 years prior to becoming a midwife.  There is a strong bias against overweight women on the OB floor.  We always talked about how long we'd have to wait before the decision was made to have a c-section.  We truly believed an overweight woman's body truly couldn't accomplish a natural birth.  It's a sad time in my "education."

    Archived User

    Many women of size gain little or no weight in pregnancy and are perfectly fine.  However, research shows there is room for concern in promoting limited weight gain as a goal for all women of size. 

    A very low weight gain increases the risk for prematurity, small-for-gestational-age babies (SGA), and possibly stillbirth.  Although the association between low weight gain and these outcomes is less strong in "obese" women, the risk IS still increased and caution is therefore prudent.  I particularly worry about the recent trend telling women of size to gain NO weight or even to LOSE weight during pregnancy.

    Weight gain in women of size is highly variable. I've been collecting informal data via my website and casual surveys among women of size for years and my data -- plus data from official studies -- seems to confirm that weight gain in women of size is all over the map.  On average, we definitely gain less than women of average size, but if you look at individuals the results are highly varied.  A few lose weight during pregnancy, some gain almost nothing, most gain around 10-15 lbs., many gain 15-25 lbs., and a few gain more. 

    Doctors usually assume that differing weight gains result from differences in caloric intake and habits, but I don't see that.  It's not irrelevant, but there's certainly not the direct connection many care providers expect.  A high BMI woman who gains 20 lbs. doesn't necessarily have worse habits than another who gains almost nothing.  There are a lot more variables than that. 

    Women of size probably gain less on average because we already have fat reserves and physiologically do not need more for pregnancy.  Also, many of us find that pregnancy revs up an otherwise-sluggish metabolism, which leads many of us to gain less.  However, women who are chronic dieters or who have recently lost a lot of weight tend to have much higher weight gains.  And there are many other factors too....which is why prenatal gain is SO variable in women of size and doesn't necessarily coordinate with habits and intake. 

    Degree of "obesity" is another variable to consider.  Recent research shows that class I obese women (BMI 30-35) who gain very little weight are at far more risk for poor outcomes than class III obese women (BMI 40+) who gain little.  But that doesn't mean that no gain or weight loss in "morbidly obese" women is benign either.

    Studies on restricting weight gain in women of size show varying rates of success.  Some find that regular nutritional consults and regular exercise help high BMI women gain less, but they also find that even on such a program, many "obese" women gain more than 15 lbs, despite doing everything "right." It's not just about intake and habits. 

    Alarmingly, several of these studies found that the rate of too-small (SGA) babies increased in the women who gained little in pregnancy, but the authors consistently shrug off this finding as unimportant.  Many of the studies also conveniently do not examine prematurity or stillbirth rates, or are not large enough to conclude that no-gain interventions are safe. None of the studies involve long-term follow-up of babies exposed to restricted intakes, and few monitor the mothers for ketones (some research shows high or consistent levels of ketones may lead to cognitive impairment in the child). 

    Therefore, I have strong reservations about strictly limiting weight gain in women of size. Personally, I think a dogmatic approach -- placing the goal on what the scale says rather than the daily nutrition and exercise of the mom -- is the wrong emphasis.  Don't manipulate a woman's nutrition to meet an arbitrary weight gain goal.  Instead, emphasize excellent nutrition and regular exercise, and trust the woman's body to gain what it needs.

    Personally, I am a class III "morbidly obese" woman and I gained about 5 lbs. net in each of my pregnancies.  This was fine for me because my nutrition was fine; it didn't come from strictly limiting intake or not being "allowed" to gain weight.  It was just my body's natural response to the increased metabolism of pregnancy.  A small gain is not automatically harmful, as long as the mom is getting good nutrition, is not spilling a lot of ketones, etc.  But promoting this as a goal and/or using draconian methods to get it -- THAT has a lot of potential for harm, in my opinon, and I have grave reservations about the current push to limit gains so strongly.

    I have a whole series on the topic of prenatal weight gain in women of size going on in my blog currently, complete with links to study references.  I should have the latest post on the topic up soon, so I invite readers to come over and read more about it at Look in the category of weight gain in pregnancy.

    Henci Goer

    Thanks for this excellent discourse on a topic all too often oversimplified.

    ~ Henci

    Archived User

    Thanks for this excellent forum.  I will be following the discussion and wanted to alert readers to the CMQCC website page on Pregnancy & BMI Resources.  Please send additional resources to [login to unmask email] to be considered for addition.   There are a range of issues that maternity providers need to consider when a woman with high BMI (>35) is admitted to the hospital. (I assume the issues are different for the home birth group).   I learned a lot about these systems factors at a recent maternity conference sponsored by an integrated/preventative focused health system.  From having the right size blood pressure cuff to ensuring that beds/tables and in-wall toilets can accomodate the woman's weight to concerns about administering an epidural safely to issues of staff safety in moving and physically supporting heavy women in labor and being sensitive to the weight issue as an emotional factor -- there are a lot of important issues and concerns that go into preparing a safe environment for a heavy patient. 

    We are currently doing analysis on three years' worth of linked data on California women's birth outcomes (vital stats-birth certificate and hospital discharge data) to examine the relationship between pregnancy BMI and birth outcomes.  This is the first ever large scale study of this type and was made possible when California added "pre-pregnancy" weight on the birth certificate in 2005.  Stay tuned for more on this as we complete our analysis. 

    Henci Goer

    Good to hear of the interest in this issue by the California Maternal Quality Care Collaborative. (Christine works for the CMQCC.) They've been doing some great work. I hope CMQCC will get in touch with the woman who blogs on the well-rounded mama for her input.  The best guidelines and policies will be developed when all stakeholders participate, including knowledgeable members of the public, which KMom certainly is!

    -- Henci 

    Archived User

    overweight women do not NEED c-sections!  I had 3 vaginal deliveries.  I am obese, have been for all three pregnancies.  Stressing fitness is the issue, rather than weight.  I have lost significant weight with all three pregnancies (not from trying) and I am CONVINCED that it is related to hormonal issues.  When my body is PG, my hormones stimulate my metabolism and I burn more calories.  I certainly do not exercise more during PG but I feel better and my body is healthier during pregnancy than it is not PG.  If we would teach women to birth upright and get her muscles fit in the lower body before and during PG, we would have women who can birth their babies without intervention.  When the adominal and groin area are comepletely out of shape, women CAN NOT push their babies out effectively, ESPECIALLY when they are laying on their backs. 

    Obese women are not all obese for the same reasons.  Just like some skinny women are naturally skinny and some are anorexic, there are reasons for obesity.  We are treated like imbeciles, like lazy oafs, like uneducated trailer trash because of our weight and this is unreasonable.  Overweight women need to focus on getting their muscles in shape for the delivery process rather than focusing on NOT eating something. 

    Just think, a large women who could hold her own weight.  The OB nurses would not have to worry about physically supporting her, only emotionally and medically.  That would be a nice change.

    Henci Goer

    You make some excellent points. I would add that the most important thing a woman of size can do to prevent a preventable cesarean is find a careprovider who doesn't think high BMI = c-section.  

    ~ Henci

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