Growing Obesity Increases Perils of Childbearing

Growing Obesity Increases Perils of Childbearing
By ANEMONA HARTOCOLLIS
Copyright by The New York Times
Published: June 5, 2010
http://www.nytimes.com/2010/06/06/health/06obese.html?th&emc=th


As Americans have grown fatter over the last generation, inviting more heart disease, diabetes and premature deaths, all that extra weight has also become a burden in the maternity ward, where babies take their first breath of life.

About one in five women are obese when they become pregnant, meaning they have a body mass index of at least 30, as would a 5-foot-5 woman weighing 180 pounds, according to researchers with the federal Centers for Disease Control and Prevention. And medical evidence suggests that obesity might be contributing to record-high rates of Caesarean sections and leading to more birth defects and deaths for mothers and babies.

Hospitals, especially in poor neighborhoods, have been forced to adjust. They are buying longer surgical instruments, more sophisticated fetal testing machines and bigger beds. They are holding sensitivity training for staff members and counseling women about losing weight, or even having bariatric surgery, before they become pregnant.

At Maimonides Medical Center in Brooklyn, where 38 percent of women giving birth are obese, Patricia Garcia had to be admitted after she had a stroke, part of a constellation of illnesses related to her weight, including diabetes and weak kidneys.

At seven months pregnant, she should have been feeling the thump of tiny feet against her belly. But as she lay flat in her hospital bed, doctors buzzing about, trying to stretch out her pregnancy day by precious day, Ms. Garcia, who had recently weighed in at 261 pounds, said she was too numb from water retention to feel anything.

On May 5, 11 weeks shy of her due date, a sonogram showed that the baby’s growth was lagging, and an emergency Caesarean was ordered.

She was given general anesthesia because her bulk made it hard to feel her spine to place a local anesthetic. Dr. Betsy Lantner, the obstetrician on call, stood on a stool so she could reach over Ms. Garcia’s belly. A flap of fat covered her bikini line, so the doctor had to make a higher incision. In an operation where every minute counted, it took four or five minutes, rather than the usual one or two, to pull out a 1-pound 11-ounce baby boy.

Studies have shown that babies born to obese women are nearly three times as likely to die within the first month of birth than women of normal weight, and that obese women are almost twice as likely to have a stillbirth.

About two out of three maternal deaths in New York State from 2003 to 2005 were associated with maternal obesity, according to the state-sponsored Safe Motherhood Initiative, which is analyzing more recent data.

Obese women are also more likely to have high blood pressure, diabetes, anesthesia complications, hemorrhage, blood clots and strokes during pregnancy and childbirth, data shows.

The problem has become so acute that five New York City hospitals — Beth Israel Medical Center and Mount Sinai Medical Center in Manhattan, Maimonides in Brooklyn and Montefiore Medical Center and Bronx-Lebanon Hospital Center in the Bronx — have formed a consortium to figure out how to handle it. They are supported by their malpractice insurer and the United Hospital Fund, a research group.

One possibility is to create specialized centers for obese women. The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean sections and intensive care for newborns, said Dr. Adam P. Buckley, an obstetrician and patient safety expert at Beth Israel Hospital North who is leading the group.

Very obese women, or those with a B.M.I. of 35 or higher, are three to four times as likely to deliver their first baby by Caesarean section as first-time mothers of normal weight, according to a study by the Consortium on Safe Labor of the National Institutes of Health.

While doctors are often on the defensive about whether Caesarean sections, which carry all the risks of surgery, are justified, Dr. Howard L. Minkoff, the chairman of obstetrics at Maimonides, said doctors must weigh those concerns against the potential complications from vaginal delivery in obese women. Typically, these include failing to progress in labor; diabetes in the mother, which can lead to birth complications; and difficulty monitoring fetal distress. “With obese women we are stuck between Scylla and Charybdis,” Dr. Minkoff said.

But even routine care, like finding a vein to take blood, can be harder through layers of fatty tissue.

And equipment can be a problem. Dr. Janice Henderson, an obstetrician for high-risk pregnancies at Johns Hopkins in Baltimore, described a recent meeting where doctors worried that the delivery room table might collapse under the weight of an obese patient.

At Maimonides, the perinatal unit threw away its old examining tables and replaced them with wider, sturdier ones. It bought ultrasound machines that make lifelike three-dimensional images early in pregnancy, when the fetus is still low in the uterus and less obscured by fat, but also less developed and thus harder to diagnose clearly. “You really need to use the best equipment, which is more expensive,” said Dr. Shoshana Haberman, the director of perinatal services.

Many experienced obstetricians complain that as Americans have grown larger, the perception of what constitutes obesity has shifted, leading to some complacency among doctors. At UMass Memorial Medical Center in Worcester, Mass., Dr. Tiffany A. Moore Simas, the associate director of the residency program in obstetrics, demands that residents calculate B.M.I. as a routine part of prenatal treatment. “It’s one of my siren songs,” Dr. Moore Simas said, “because we are very bad at eyeballing people.”

Dr. Haberman said there was obesity in her own family, and she had seen how hurtful even professionals could be. “We as a society have issues with the perception of obesity; anatomically, you get turned off,” she said.

So she was sympathetic to Ms. Garcia, making sure she got a room with a window, and calling to check on her after hours.

Ms. Garcia, 38, a former school bus dispatcher, is 5 feet tall. She said she had tried diets, weight-watching groups and joining a gym. She was 195 pounds before her pregnancy (B.M.I., 38) and ballooned to 261 pounds, which she attributed to water weight and inactivity.

“I’m the smallest one in my family,” she said. Her older brother weighed more than 700 pounds before having gastric bypass surgery.

She wiped tears away as she confessed that she worried that she might die and leave her baby without a mother.

At Ms. Garcia’s stage of pregnancy, every day in the womb was good for the baby but bad for the mother, Dr. Minkoff said. “She’s making a heroic decision to put her own self in peril for the sake of the child,” he said.

She survived, but was dismayed by the size of her son, Josiah Patrick, who had to be put on a breathing machine. At first she could see him only by remote video. But after a month, Josiah was off the ventilator, taking 15 milliliters of formula and had smiled at his mother, and doctors said he was where he should be developmentally for a preemie his age.

The hospital estimated that the cost of caring for the mother and baby would be more than $200,000, compared with $13,000 for a normal delivery.

Ms. Garcia promised Dr. Minkoff that she would lose weight and see her baby graduate from college. “I’m going on a strict, strict, strict diet,” she said. “I’m not going through this again.”