This is my first post, and I will do my best to participate and not just take advantage of this service. This paper is required to be reviewed, and I don't personally know anyone with the time, inclination, or expertise to evaluate a paper, because I am the first in my family to attend higher education. The following is the description of the assignment, as provided by the professor. I am particularly concerned about my paper's organization and flow, as well as transitions. I appreciate any help anyone is able to provide me.
Thank you for being willing to consider reviewing my paper.
Cheryl Staudt
Health Care Provider Weight Bias: Its Existence and How It Can Affect Obstetric Care
Most people would agree that having a child should be a time for celebration and joy. If a woman is overweight or obese, there may instead be worry and fear. Healthcare providers are generally as prone to weight bias as other individuals in society, so women who are overweight or obese may be refused services or find services unavailable or difficult to access; be treated in a discriminatory, abusive manner, or other negative manner because of their weight; have facilities or options be unavailable; or be required to do or receive additional testing or substandard care due to weight bias and poorly evidenced practices during their pregnancies.
When there is society, it is not unreasonable to expect that all the individuals within it will reflect that society. Healthcare providers are part of our society, and as such are subject to the same preconceptions and biases as the rest of us. Studies have found that people who have obesity are often associated with negative traits, such as laziness, incompetence, ignorance, noncompliant, and lacking hygiene by physicians and other health care providers charged with caring for them. (Huizinga, Cooper and Bleich; Puhl and Brownell; Merrill and Grassley) In one study, the medical students being evaluated actually looked at an overweight patient's face 20% less often, and were less inclined to touch the patient. (Eccleston and Persky)They were also more likely to recommend lifestyle changes for shortness of breath instead of treating the symptoms with medication or recommending further clinical evaluation of the symptom or testing. (Eccleston and Persky) This trend continues into the nursing sphere of influence. "48% of nurses agreed that they felt uncomfortable caring for obese patients, and 31% would prefer not to care for an obese patient at all." (Puhl and Brownell) To believe that obstetricians, nurses, and midwives are immune to societal bias when it is apparent that other medical professionals are not would be to ignore the ample evidence.
Women who are overweight and find themselves pregnant can experience difficulties from the moment they decide to walk into a provider's office. Some midwives, for example, either won't treat obese women at all, or use fear tactics and shame to make the woman pledge to obey the midwife's recommendations. (Vireday) Certain obstetricians will completely refuse to provide care for an obese individual. Some providers are of the belief that an obese woman cannot become pregnant, and therefore may assume the woman is either delusional or lying until she proves she is pregnant by one or more pregnancy tests administered by the provider's office at insurance or personal expense before the woman can make an appointment. (Merrill and Grassley) After it is determined they are pregnant, some fat women have been told by their providers that they must terminate the pregnancy because the fact that they are overweight could cause neonatal death of the fetus anyway. (Vireday)
After finding the courage to face a provider, the office may not even have a suitable place for a pregnant obese woman to sit while waiting for the appointment. (Vireday) A lack of chairs without arms or comfortable couches could ensure a pregnant woman of size has to stand during the wait to be called back to a room. A lack of size-appropriate equipment is not just a comfort issue. Using the wrong size blood pressure cuff can give erroneous readings for blood pressure, usually high. Some scales have a top weight of 250 pounds, making further readings erratic or impossible. Speculums may be the wrong size or the wrong material. Examination tables may be unstable or unsafe. Many offices don't stock gowns large enough to comfortably cover an extremely overweight woman, increasing discomfort. These issues that can cause erroneous readings often require a prudent provider to do further testing, which would not have been necessary if appropriate equipment had been available. Extra testing, not being believed, and being told false or misleading information are all hazards that an obese woman must be prepared to face when discovering she is pregnant.
There are guidelines for providers to follow for different weight groups when managing prenatal care, once a woman is at the point where she is actually receiving care. In these standards, providers are supposed to record initial weight and height, make lifestyle recommendations, evaluate weight gain, perform certain testing procedures, and monitor certain biological changes in mother and fetus. (The American Congress of Obstetricians and Gynecologists: Committee on Obstetric Practice) The weight gain officially recommended is 25 to 35 pounds for normal weight women, 15 to 25 pounds for overweight women, and 15 pounds for obese women. Despite these formal recommendations, many providers actually recommend significantly different amounts to their patients. One study found that over half of obstetricians surveyed recommended a maximum of five pounds of weight gain for their obese patients, and a weight gain of 10 to 15 pounds for their overweight patients. (Herring, Platek and Elliott)
The approximate breakdown of studied weight distribution is seven to eight pounds for the fetus, one to two pounds for the placenta, two pounds of amniotic fluid, two pounds for uterine growth, two pounds of breast tissue, four pounds of maternal blood, four pounds of fluid buildup, and seven pounds of fat and nutrient stores. (The American Congress of Obstetricians and Gynecologists: Committee on Obstetric Practice) This is a minimum of 22 pounds, even if the mother doesn't increase her fat stores at all. By recommending five pounds of weight gain, some obstetricians are actually recommending a 17 pound weight loss during pregnancy for their obese patients. Despite this, many doctors objected to the modification of the recommendations in 2009, believing that the recommendation in the obese category was still too high, and that little to no weight loss was preferable. Dr. Raul Artal was quoted in The Los Angeles Times saying "In my opinion, the Institute of Medicine is missing an opportunity to address the issue of the obesity epidemic and the contribution that pregnancy makes to that epidemic." (Roan)
The typical prenatal appointment encompasses several tests, including a weigh-in to measure weight changes and initial weight if necessary, and a urine analysis to look for ketones and protein. Additional tests are recommended based on the stage of gestation. Some women report being shamed at the weigh-in. Some express humiliation at being weighed in public areas, having their results announced loudly, or being chastised for the results of the medical test in the common areas. (Merrill and Grassley) ACOG, the American Congress of Obstetricians and Gynecologists, recommends screening for gestational diabetes in the first trimester as well as the third trimester, due to increased risks in the overweight population. (The American Congress of Obstetricians and Gynecologists: Committee on Obstetric Practice) Some people who have worked closely with the medical field see women being requested to screen for gestational diabetes at every appointment, which is once a week in the last month of pregnancy, because the obstetrician is certain the women will develop the condition due to her weight and therefore apparent lack of proper diet. Shame is sometimes used to ensure compliance with enhanced testing procedures.
Additional testing often recommended to overweight and obese patients includes multiple ultrasound exams and amniocentesis. Ultrasound is essential in earlier trimesters for detecting fetal anomalies, neural tube defects, and other problems, and can be important later to monitor known problems with the placenta or fetus. It is not fully studied for pregnancy, and while considered safe, it is recommended that ultrasound exams be limited and only used for specific diagnostic reasons. There is no known safe or unsafe level of ultrasound for fetuses, and fetuses have been known to become agitated by or move away from the ultrasound source. An analogy could be the use of X-ray in pregnancy, once believed to be safe, but now known to be hazardous over time. Amniocentesis is used to detect chromosomal abnormalities, but has a 1 in 200 chance of causing a miscarriage, a greater risk than the conditions it tests for in many cases. Unlike ultrasounds, this test is not low-risk, and is generally used after several other tests are performed in non-obese people. Often, those tests can be more difficult or uncomfortable for the health provider due to the mother's size. Some providers will proceed to an amniocentesis for results that are less abnormal than a normal-weighted woman's who was not recommended an amniocentesis. Despite the additional risks of harm to the fetus and difficulty in acquiring the requisite samples or scans in larger women due to excess adipose tissue, these tests are more likely to be performed "just in case", as opposed to in response to risk factors, as well. (Chu, Bachman and Callaghan) Studies have shown that doctors and other pregnancy care providers are more likely to order invasive tests, medications, ultrasounds, and extra doctor visits for obese low-risk patients than for their normal-weight high-risk patients. (Chu, Bachman and Callaghan; Abenhaim and Benjamin) Non-compliance with provider recommendations for extra screenings or misgivings about the necessity of these repeated tests and their costs sometimes resulted in chastisement for beginning the pregnancy above normal weight and occasionally allegations that the mother-to-be didn't care about the life and well-being of the unborn child. (Merrill and Grassley)
Overweight and obese pregnant women are also more likely to be induced, have an operative vaginal delivery, or be required to schedule an elective cesarean, despite the risks of induction, birth interventions, and surgery being higher in pregnant women of size and their babies. (Declercq, Sakala and Corry) The risks of shoulder dystocia, macrosomia, and other childbirth complications are slightly but statistically significantly higher in obese and overweight women, (The American Congress of Obstetricians and Gynecologists: Committee on Obstetric Practice) but these risks are still very small if there are not other complications such as gestational or other diabetes, high blood pressure, or preexisting medical conditions. Doctors and midwives will sometimes, after ordering tests not ordered for normal weight patients, find slightly suspicious information that causes them concern, such as low amniotic fluid measurements or babies estimated to be eight pounds. In these cases, providers are less likely to take a wait and see approach as compared to their normal weight patients. (Abenhaim and Benjamin) In fact, approximately one quarter of pregnant women of size are likely to be pressured by their health care provider into an elective cesarean surgery, and approximately one seventh of them are likely to be pressured to induce. (Declercq, Sakala and Corry) With the tactics used to ensure compliant patients, including scare tactics and humiliation techniques, this increases the elective induction and surgical delivery rates of obese women. (Vireday) An induction is the biggest risk factor for emergency cesarean surgery in obese pregnant women. (Chu, Bachman and Callaghan; Abenhaim and Benjamin) Obese and overweight women are also more likely to experience forcep delivery, vacuum delivery, and labor practices such as internal fetal monitoring, in which they screw an electrode into the unborn baby's scalp, or constant fetal monitoring via belts on the abdomen. If any of the monitoring methods produces something that worries the attending provider, these indications can be used to further pressure the mother into an elective cesarean.
Despite evidence recommending otherwise, obese and overweight women are more likely to be delivered by sub-optimal cesarean practices, such as a vertical, T-shaped, or cross-shaped incision instead of a transverse or bikini incision, which can increase the likelihood of surgical complications and danger of subsequent pregnancies and deliveries. (Chu, Bachman and Callaghan; Abenhaim and Benjamin; Declercq, Sakala and Corry; Herring, Platek and Elliott) A T- or cross-shaped incision is usually reserved for the most emergent cesareans, as they are more difficult to heal and more likely to experience wound separation and infection. A T- or cross-shaped incision is also a contraindication for Vaginal Birth After Cesarean, or VBAC. Doctors have admitted in private that they have used these less desirable incision types in order to prevent VBAC specifically in obese women. Women have been told they received the vertical incision instead of a safer transverse incision because "you are not likely to ever wear a bikini." (Vireday) Incisions other than transverse decrease the likelihood of success for future VBAC, as well as the danger of subsequent pregnancies. A T- or cross-shaped incision is a contraindication for Vaginal Birth After Cesarean, or VBAC. Many women feel that these sub-optimal incisions are done to punish them for daring to be fat while pregnant, and to ensure that they are less likely to become pregnant again. (Vireday)
When all the testing, interventions, inductions, and surgical deliveries are added up monetarily, the pregnant obese person often ends up paying more out of pocket and consuming more health care dollars without statistically noticeable improved outcomes. Most insurance companies cover specific tests and procedures at specific points in gestation, which are generally correlated with best practices or ACOG recommendations, and require medical verification of need from a primary care physician in order to approve any extra testing. With no documented improvements in neonatal outcome, these tests are often not covered. Any additional testing that isn't covered will have to be paid for out of pocket, ensuring that a pregnancy for an obese woman has the potential to be significantly more expensive than that of a non-obese person.
It is evident that an overweight or obese woman will need to be well-informed about what is appropriate during her pregnancy in order to keep monetary, physical, and emotional costs down. Finding the right provider is the most important way a pregnant women, no matter her weight status, can ensure the most effective care for herself and her unborn child. By speaking to and about providers, women can identify providers with similar beliefs and sympathetic personalities. Pregnant women should ensure that they understand the concept of informed consent and informed refusal, and obtain the information they need to make an informed decision about health care practices during their pregnancies. Having the right provider can go a long way to ensuring that a woman's decisions are honored and not ridiculed. If a woman is well informed and has a provider that takes the limits, risks, and challenges of obesity into consideration without abuse or causing physical or emotional hare, then the pregnancy of an overweight or obese woman can be the time for celebration and joy that people believe it should be.
