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)

 

BBC News – Delay pregnancy after obesity surgery, women warned

Interesting news for anyone considering weight loss surgery before trying get pregnant.

Even though you’ll have lost the weight, you still won’t escape the ‘high risk’ bracket, and will likely receive much of the same treatment that you would if you were still big. Furthermore it seems that a number of things could go wrong, a significantly increased risk of miscarriage being one of them, if you get pregnant within 18 months of the surgery (31% of pregnancies occurring within 18 months of surgery, as opposed to 18% of pregnancies occurring 18months+ after surgery).

BBC News – Delay pregnancy after obesity surgery, women warned.

Comes from this study:

Pregnancy outcome following bariatric surgery (12.1 KiB)

Which looks at different research, some of which compared pregnancies after different types of weight loss surgeries against each other, some against those of obese patients who haven’t undergone surgery, and some against ‘healthy weight’ women.

The text (and sub-text) is quite interesting:

“Case–control studies demonstrate increased fertility following bariatric surgery, although these studies lack complete data and statistical significance due to small sample sizes.”

It would be interesting to see whether this is due to the positive effect of weight loss on Poly Cystic Ovary Syndrome in particular, which is known to affect fertility the heavier you are, or whether in general it improved fertility for larger women.

“Post-LAGB [Laparoscopic adjustable gastric banding] pregnancies are not without complications. Band slippage and migration can result in severe vomiting. Band leakage is reported in 24% of cases.”

Sounds tempting.

“Mild nutritional deficiencies are frequent after bariatric surgery”.

 

“Significant malabsorption in the mother can affect the energy content of breast milk and may affect the postnatal growth of the baby”.

The solution given for this is to supplement breast milk with formula. But mixed feeding with both bottle and breast is a significant indicator for stopping breastfeeding sooner.

“Aside from nutritional deficiencies, case reports have documented risks of intestinal hernia (most commonly reported), intestinal obstruction, perforation and death in pregnant women post-RYGB [Roux-en-Y gastric bypass].”

Hmm. Again, tempting.

If you are considering gastric surgery because you were concerned about having a caesarean or induced labour:

“Overall, bariatric surgery does not appear to reduce the risk of CD [caesarean delivery].”

 

“Another study showed higher labour induction rates as compared with non-obese comparison groups.”

There may also be reasons not to consider certain types of bariatric surgery if planning to get pregnant. One study reported:

“higher congenital malformation rates following BPD [Biliopancreatic diversion].” and

 

“Miscarriage rates following BPD [Biliopancreatic diversion] may be higher.”

Finally,

“There is no strong evidence that adverse neonatal outcome rates are higher following  LAGB and gastric bypass procedures as compared with obese groups”.

So reading between the lines, there is evidence that outcomes for babies aren’t as good following surgery, just not strong evidence?

But my personal favourite is:

“maternal and fetal outcomes are acceptable with LAGB and gastric bypass”.

Acceptable? What does that mean?

On the positive side:

“Most studies report a reduced incidence of GDM [gestational diabetes mellitus] in
patients following bariatric surgery.”

 

“Studies comparing pre- and postbariatric surgery pregnancies consistently show that the incidence of PIH [pregnancy induced hypertension or high blood pressure] and pre-eclampsia is lower following surgically induced weight loss than the risks in obese women.”

The study concludes:

“In light of current evidence available, pregnancy after bariatric surgery is safer, with fewer complications, than pregnancy in morbidly obese women”.

Hmm. I’m struggling to be convinced. 21% of post-surgery pregnancies reported problems according to one study. Though I can’t find a comparable statistic for obese women who have not had weight loss surgery, that doesn’t seem like great odds. Presumably the reduction in serious complications like pre-eclampsia are significant enough for the authors to reach this conclusion.

As always, it’s for you to make up your own mind, but at least here’s some information for you to get started.