Why hospitals need to grant pool access to bigger women

Anyone who has followed this blog for a while will know that I strongly believe hospitals need to grant pool access to women with higher BMIs.

My being denied access with my first-born is one of the reasons this blog even exists! I’d discussed it at every appointment, was promised a pool birth in the hospital (so long as the pool in the delivery suite wasn’t occupied when I needed it), taken on a tour of the pool room, but then repeatedly denied access to the pool while I was in labour until someone finally told me at 8cm dilated that I would not be allowed to use it after all. It’s also the reason I chose to have my second baby at home!

Hospitals need to grant pool access to bigger women - Big Birtha's Home Water Birth

My second labour and birth, where I did have access to a pool, confirmed everything I had suspected. The warm water was incredible at helping me manage the pain of contractions! Coupled with that, the buoyancy provided by the water meant that I could move around with ease. I was so much more comfortable and relaxed – even during contractions!

The frustrating thing is there’s no evidence to support restricting access!!

To be honest, there’s not a lot of good-quality evidence about the use of birth pools full stop. But because so few women get access to water birth there’s no data to show it’s safe for larger mums. But because there’s no data to show it’s safe, we’re denied access! Anyone see a problem here?

I’m not alone in thinking this!

It turns out that Health Care Professionals are beginning to notice this. So I’m delighted to report that the Association for Improvements in the Maternity Services asked me to write an article for their journal, complete with oodles of references for you to wave in the faces of healthcare naysayers you may meet. Enjoy!

AIMS Journal Article featuring Big Birtha

https://www.aims.org.uk/journal/item/waterbirth-high-bmi

BigBirthas PSG Research Results!

So, you’ll want to know what happened to the BigBirthas PSG research results? What did we get up to in collaboration with the Parenting Science Gang?

Well, we’re all done. We put out the initial calls to join our Facebook group back in March 2018. Thank you to everyone who joined in. 161 people joined the Facebook group, and we’re still actively discussing issues even now the research has concluded! We held dozens of expert Q&A sessions, and some of the experts sounded like they enjoyed it as much as we did!

Join our Facebook group!

The BigBirthas PSG Research Topic

Conversations within our group revealed that many of us felt our choices were unfairly limited during pregnancy and labour. Our experience suggested that a high BMI leads to health care professionals restricting the choices which are normally available. We also felt that often, there was no medical evidence to suggest that our preferences weren’t perfectly reasonable. Many of us had had very negative experiences, even when our pregnancies were otherwise uncomplicated.

We decided to research how choice is presented to mothers with a high BMI and how that affects maternity experience. Were our situations typical? Or had our negative experiences made us unaware of high-BMI women with less traumatic stories?

We recruited volunteers from anywhere and everywhere in the UK we could think to ask. We were then overwhelmed by the enthusiastic response! Almost immediately, 60+ women responded to our request for research interviewees. 20 of those swiftly completed the full-length responses we needed to do our qualitative study using thematic analysis methods.

Then we stopped asking for respondents, because 20 was about the limit we could manage! Especially with just a small group of first-time thematic analysts running the show!

But that’s the point of Parenting Science Gang; let the parents be in charge of asking the questions they want answered, and of working out how to do it!

The Full BigBirthas PSG Research Findings

Please be aware, that for some, reading other people’s stories can trigger upsetting memories of our own experiences at a time of our most intense vulnerability, so if you do read the full document, please bear this in mind.

You can read our BigBirthas PSG Research Results here: Big Birthas’ Findings

What did we find out?

We did not uncover any great surprises. Our results confirmed that the conversations our group had had were pretty typical. There were a few great stories about knowledgeable health care professionals treating mothers with dignity, but we also found clear themes of unsatisfactory treatment. Several reported observing an immediate change of tone after being weighed:

“When I’d been weighed and measured she immediately started saying things like “Oh, there will be a problem because of your weight” but wouldn’t explain what the problem was. She wasn’t as friendly then and wouldn’t explain things to me”

Language changed, and some mothers felt lectured and patronised. There were almost constant warnings about potential problems (most of which never transpired), repeated tests for conditions (many of which never developed), with some health care professionals resorting to “persuading” mothers using guilt tactics.

“I felt that I was coerced and guilted into an additional scan by one particular midwife.”

“Felt that I didn’t have a choice, I was scared into decisions.”

“I was told ‘Well you must have known the risks when you decided to get pregnant, being the weight you are.”

First Pregnancies

In most cases, first-time around, mothers reported following the recommendations of health care professionals unquestioningly. This too echoed our experiences in the group. It was only after the first birth that many realised that they should have had a choice.

“I didn’t realise you could refuse induction”

“In both labours vaginal examination was presented as a non-option.”

Some mothers reported being ignored:

“I was given all the interventions including an epidural that I had refused”

“First time round I agreed to one [vaginal examination] and the midwife swept me without my consent.”

Disagreements Between Health Care Professionals

Worryingly, many mothers reported finding a great discrepancy between health care professionals, in terms of knowledge and subsequent behaviour. Sometimes mothers found that their weight was the scapegoat for everything with a few professionals, but that others didn’t agree.

“The first sonographer very harshly said that the reason she had trouble was because I was quite fat so it was harder to get a good picture. During other scans I was told that weight doesn’t necessarily come into it and it really does depend on the competency of the sonographer and the position of the baby/womb/placenta”

Many mothers received conflicting messages about risk and options from different professionals. This was both confusing and upsetting, and didn’t inspire confidence in the system to provide for their needs.

“I felt that people knew best, but when professionals are literally disagreeing about the well-being of your unborn baby, it’s a bit disheartening.”

Stress

This lack of consistency, coupled with feeling judged and unsupported had a strong effect on mothers, many of whom reported that pregnancy had been an extremely stressful time for them.

“I found it scary and confusing during my first pregnancy.”

“I left some midwife appointments afraid that I might die in labour!”

Second Pregnancies

Not unexpectedly, mothers prepared for subsequent pregnancies with care. No one mentioned losing weight, but many mothers talked about being much better informed. Many read up on guidelines and risks, were more confident in asserting their views and wishes, and challenged health care professionals to explain themselves, their actions and their recommendations.

“I had the confidence (or some might say bad attitude) to say, I’m not having all of those scans – they aren’t necessary and are a waste of my time.”

Many approached their relationships with health care professionals differently second time around. This manifested itself in their making a concerted effort to form respectful and supportive relationships from the start, either by seeking out professionals they had found supportive in their first pregnancies, or by actively avoiding certain individuals. In several cases women said they had paid for independent midwives or doulas to support and advocate for them.

Sadly, in several second pregnancies, mothers also reported avoiding health care professionals wherever possible; engaging as little as possible and refusing appointments. More than once, mothers reported needing to do this for the sake of their own mental health. This is clearly a very worrying result; it cannot be ideal for any mother, irrespective of medical needs, to be avoiding the service provided to support her. This did however, seem to be a common reaction to prior bad experiences.

Risk Presentation

We know (and I have complained many times!) that many of the risks in pregnancy are delivered in terms which make them sound excessively alarming. For example, where a risk changes in likelihood from 0.1% to 0.3%, it is often represented as “THREE TIMES THE RISK” in big, bold letters, which makes the difference seem very extreme, when it is actually still very low risk.

These alarm bells are also usually rung when the mum is already pregnant, so NOT a safe time to diet or do anything about it, and just increases the stress and feelings of guilt. This is not helpful, and given that no respondents mentioned consciously trying to lose weight between pregnancies, such an approach is clearly not serving any weight-loss motivational purpose either.

There are examples of great care, but until we are able to universally provide larger mums with a respectful and compassionate experience, ensuring they feel in control, then many more mothers will suffer from unnecessary stress during pregnancy, with the result that some will avoid health care professionals altogether, potentially putting themselves and their pregnancies at greater risk.

Thank you to the Parenting Science Gang Team!

Huge thanks to the Parenting Science Gang Team for bringing this project to fruition, for being such lovely, patient, intelligent, enthusiastic ladies, and particularly to Sophia for birthing PSG in the first place. Long may PSG continue gaining funding and doing Citizen Science into all sorts of topics, because it’s bloody ace.

Go and have a look at the Parenting Science Gang page! This link says pretty much everything I’ve said above, worded pretty similarly, but if you have a mooch around, there’s all sorts of fascinating information about the other groups and their experiments on breastmilk, baby wearing, picky eating, homeschooling and more: http://parentingsciencegang.org.uk/experiments/big-birthas-findings/

If you’d like to join us, the BigBirthas Facebook group is still going. Feel free to come and pick our collective brains, have a chat, discuss unicorns, it’s all good! We chat about all topics BigBirthas related, and anyone can post a question for the wisdom of the hivemind to respond. You’d be very welcome.

xx

Big Birtha

Time To Have Your Say!

The Royal College of Obstetricians and Gynaecologists is seeking feedback from women on its new leaflet ‘Being overweight or obese during pregnancy and after birth‘.

The closing date for comments is midday on Friday 18 May.

Click on this link to access the RCOG page where you can read the draft leaflet and then feed back your thoughts via their online questionnaire. Make sure you feed back on the right one – NOT the hysteroscopy one (unless you happen to be interested in that too!)

I don’t want to prejudice your thinking, so I’m not saying what I wrote, but I will say that it’s nice to be asked our opinion at last!

Aaand… while you’re busy having your say, let me do another shameless plug for our Big Birthas Parenting Science Gang over on Facebook. We’ve been discussing the topic and what we might research for a little while, spoken to some really interesting experts to get their views; this week we’re talking to experienced midwife and waterbirth expert Dianne Garland (SRN RM ADM PGCEA MSc) of www.midwifeexpert.co.uk. We’re nearly at the point of deciding what we’re going to research – come along and get involved, you don’t have to be a scientist (I’m not!) to get involved in citizen science!

Abortion Delays for BMI 40+?

I was quite surprised to discover today that being overweight can not only affect the maternity and antenatal care you receive, but if you’re seeking a termination of pregnancy, it can cause you problems there too.

The British Pregnancy Advice Service (the UK’s leading abortion care service) have today released a briefing paper to highlight the number of women who are being forced to continue with pregnancies against their will, and sometimes against medical advice, because of delays and lack of capacity in the system.

On 46 occasions in 2016 and 2017 – or generally twice a month – BPAS was unable to secure suitable NHS hospital treatment for women by the strict legal cut-off point of 24 weeks.

In other cases, there was significant delay between the woman presenting for treatment and being able to access that treatment: one mother with cancer, whose treatment could not start until the abortion was performed, waited 45 days for an appointment. In another case, a mother with epilepsy and learning difficulties who presented at the end of first trimester was treated nearly 7 weeks later.

But where does high BMI come into this?

Three of the cases for whom BPAS could not find an appointment in time are described thus in the paper:

BMI over 40. Existing children.
Pregnancy is the result of a sexual assault.
Presented at 22 weeks.
No appointment available.

19 years old with three young children. BMI>40. Her ex-partner has recently been released on bail following a prison sentence for domestic violence.
Presented at 19 weeks. No suitable appointment available.

BMI over 40. 18 weeks pregnant. Daughter was recently violently assaulted and raped; she feels unable to cope with both a new baby and supporting her daughter through this experience. Cannot stay overnight and leave her other
children. No suitable appointment available.

Why is this?

While most abortions in the UK are performed outside the NHS by the not-for-profit sector, in stand-alone community clinics run by organisations like BPAS, women with co-morbidities must be managed within a hospital setting where there is swift access to backup care and specific clinical expertise in the event of an emergency.

BMI is included in these co-morbidities, with the cut-off being a BMI of 40, and in fact, according to BPAS’s statistics, it’s the fourth most common reason for referral for treatment.BPAS referrals by reason

The briefing goes on to show that many of the clinics they would refer these women into will only treat women up to a certain point in their gestation, so the later you present for treatment, the fewer options you would have in terms of a location to access the service you need. There are just 35 sites across the country offering this service to women, but if you don’t discover you’re pregnant until several weeks along, this can drastically reduce your options.

NHS referral abortion sites vs gestation

I can’t imagine coming to the very difficult decision of terminating a pregnancy and then finding you are compelled to continue with it anyway because of a lack of access to appointments.

So, where does this leave us?

One in three women will have an abortion in her lifetime, and according to government statistics, 3.6% of women have a BMI greater than 40.

So, on a rough guesstimate of the figures, it stands to reason that around 1% of the population may find themselves in exactly this situation.

If you’re considering a termination, and you have a high BMI, it looks like the sooner you approach a provider for treatment, the more likely you are to be able to access it, and access it in a location convenient to you. Perhaps in this instance it’s better to approach the provider even while you’re in the process of making up your mind, in order to buy you time to arrange a suitable appointment.

But according to this study of 4968 women in 2016,

Safety of Outpatient Surgical Abortion for Obese Patients in the First and Second Trimesters (75.5 KiB)

abortion clinics needn’t be restricting access to women with high BMI at all? Is this yet another thing we should be fighting to be treated the same as any other women?

We’re damned if we do, and damned if we don’t.

Medically complex women and abortion care (425.4 KiB)

Obesity Statistics (5.7 MiB)